Man who underwent rare cardiac surgery gets insurance claim

Calling the clause under cashless medical insurance policy that requires 24-hour hospitalisation ‘unreasonable’,the Mumbai Suburban Consumer Redressal Forum recently ordered a firm to pay the claims made by an Andheri resident who underwent a rare cardiac treatment.

Dharamdas Pritiani,who underwent a rare medical treatment for his heart ailment,was denied the insurance claim of Rs 1.18 lakh by the company. In 2009,Pritiani underwent angiography at the Hinduja Hospital and learnt that he needed an immediate treatment for a heart problem. Pritiani,in his petition,claimed he went to I P C Heartcare Hospital and underwent a treatment called Enhanced External Counter Pulsation. The treatment is available only in 40 hospitals across the country and is one of the widely used methods in the western countries as an alternative to angioplasty.

However,when Pritiani sent the papers to the insurance company,he was denied the claims. The company denied the claim on the grounds that the treatment was not recognised by the Indian Medical Council and that Pritiani was not hospitalised for 24 hours,as required under the policy.

The forum chaired by V G Joshi and J L Deshpande observed that some treatments,which a patient can undergo without hospitalisation,should be covered under the insurance policy. It also said that a treatment which is widely accepted in the western countries and is used by the registered hospitals in India,should be covered under the policy. The insurance company was ordered to pay the claimed amount with an interest of 9 per cent and additional Rs 5,000 against the mental agony caused to Pritiani.