In a development that would bring cheers to the health insurance policy holders, who are undergoing Covid-19 treatment in big hospitals, Milind Kharat, Insurance Ombudsman, Mumbai & Goa, has directed Bajaj Allianz General Insurance, to pay one of its customers the entire hospitalization expenses, barring non-medical items, incurred for Covid-19 treatment.
Abhay Chhapia, who had bought a health insurance policy from Bajaj Allianz General Insurance, with a sum assured of Rs 30 lakh, had availed of medical treatment in Mumbai based Wockhardt Hospital for Covid-19.
However, Chhapia had filed a complaint with the Ombudsman against short-settlement of a claim lodged under the policy by Bajaj Allianz General Insurance. He complained that a claim lodged for Rs 3.1 lakh for the treatment of Covid-19 (positive) undergone by him at Wockhardt Hospital was settled by Bajaj Allianz General Insurance on cashless basis with a deduction of Rs.1.3 lakh almost half the amount of claim.
He stated that he has been associated with the company for many years and further argued that he, as an individual, has no say or bargaining power in front of the hospital and had to pay whatever amount was charged to him.
After scrutinising the documents produced on record coupled with the depositions of both the parties, Kharat observed that the hospital has not adhered to Preferred Provider Network (PPN) rates and has overcharged the patient in violation of their agreement with the Bajaj Allianz General Insurance. “Nevertheless, it would not be fair to penalise the policyholder for the same as he has genuinely incurred the expenses and has paid the charges as billed by the hospital. We are of the view that the policyholder is entitled to be reimbursed the entire hospitalization expenses barring non-medical items and the Bajaj Allianz General Insurance may seek refund of the amount billed in excess of agreed rates directly from the hospital,” Kharat’s order said.
The award of insurance Ombudsman is binding on the insurers.
In a statement, Bajaj Allianz General Insurance said, “the insured had approached us for cashless claim which was approved within agreed SLA and as per policy T&C. The Ombudsman directed us to pay balance admissible claim amount barring the non-medical expenses. On further scrutiny we identified Rs 6,897 was inadvertently missed (comprising Rs 6,000 towards dietary charges deducted, Rs 640 towards IV Canula, Rs. 250 towards Emergency rent and Rs 7 towards Blood Safety Lancet Sd Biosensor) barring the non-medical expenses (NME) which we have paid to the customer and informed the Ombudsman accordingly. The rest of the NME deductions were as per IRDAI approved list of NME charges.”
“Overall, we have paid additional Rs 6,897 as per Ombudsman award against the relief sought by customer of Rs 1,22,885,” the company said.
According to the Ombudsman, the company had contended that the policyholder had lodged a claim for medical expenses of Rs 313,445 which was approved for an amount of Rs 152,039 by deducting non-medical expenses and Rs 125,215 towards clinical facilitation & safety, clinical nutrition, Covid hygiene, Covid waste management, medical registrar visit fees, rehabilitation charges and excess PPE kit charges.
“The respondent stated that they have already paid room charges of Rs 5,000 per day and housekeeping charges are not payable under any claim as per the terms & conditions of the policy. Also, the policy provides for payment of specialist’s fees but RMO (Resident Medical Officer) charges are not payable separately. They have paid Rs 650 per PPE kit,” Ombudsman said.
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