AYUSH treatment on par with Allopathic treatment for Reimbursements: HC

Chennai: The Madras High Court recently asked the Insurance Regulatory and Development Authority of India (IRDAI) to treat AYUSH treatment on par with Allopathic treatment while reimbursing expenses incurred during treatment.

IRDAI has also been directed to reimburse the insurance amount on equal scales for both branches of medicine. "There shall be a direction to the third respondent to act upon the suggestion made by this Court to place AYUSH treatment on par with alopathic treatment and direct the insurance companies to reimburse the insurance amount on equal scales," ordered the HC bench comprising Justice N. Anand Venkatesh.

The HC bench also referred to the COVID-19 pandemic and pointed out that during the pandemic, traditional medicines were recommended for the infected persons. Effective treatment was provided under AYUSH, which provided substantial relief to the patients, noted the HC bench.

"In such circumstances, it will not be reasonable to restrict the cap and thereby deprive the policy holders to get reimbursement of the amount, which was spent by them in AYUSH hospitals," opined the Court.

At this outset, the court also reminded the IRDAI that patients can choose the type of treatment that is required for them and they have an option to either choose alopathic medicines or go for traditional medicines provided by AYUSH.

Therefore, the court opined that whatever expenses are incurred for either of these treatments must be placed on equal scales. "It will be discriminatory to give preference to allopathy as against AYUSH treatment. This must be kept in mind by the third respondent whenever the policies are drafted and sent for approval," it noted.

The Court also expressed its opinion that traditional treatment in India, which falls under the head of AYUSH treatment must also be encouraged and it must get the same weightage as is given to allopathic treatment. Therefore, a person , who chooses to undergo AYUSH treatment should be entitled to receive the insurance amount towards the expenses incurred by him, as is done to a patient who undergoes allopathic treatment. "This has to be implemented by the third respondent in all future policies," the Court noted in its order.

These observations were made by the High Court while considering two petitions seeking full reimbursement of the amount claimed by the petitioners under their respective Insurance Policies.

One of the pleas was filed by an Advocate who had taken a policy for a sum of Rs 5 lakhs and the other one was filed by a clerk who took a policy for a sim of Rs 4 lakhs.

Both of them got infected with COVID-19 and sought treatment at Siddha Hospital. Both of them sought a reimbursement of Rs 52,250 each which was incurred in treatment. However, only Rs 15,000 and Rs 10,000 were reimbursed to them.

They submitted that when they took the policies in the year 2009, it did not provide for any separate cap for reimbursement towards treatment taken in AYUSH Hospital, and the same was treated on par with Allopathy treatment. Therefore, it was contended that whatever amount was spent towards the treatment in Siddha Hospital must be reimbursed by the Insurance Company.

On the other hand, the insurance company submitted that the Policies are governed by the regulation issued by IRDA from time to time and as per the same, a maximum cap is fixed on the maximum amount of reimbursement for AYUSH treatment.

As per the Insurance Company, IRDAI policy states, that for a sum of Rs 5 lakh, a maximum of Rs 15,000 and for a sum of Rs 4 lakhs, a maximum sum of Rs 10,000 can be reimbursed. Referring to these, the company submitted that the said amount had already been reimbursed to the petitioner.

While considering the policies, the HC bench noted that under the policy, the expenses incurred for the treatment under the system of medicines other than allopathy were excluded. The court also took note of the fact that the maximum amount of reimbursement allotted to the petitioner under the respective caps for AYUSH treatments had been disbursed to the petitioners and no further directions could be given to the Insurance Company.

However, the Court took note of a larger issue and highlighted the discrimination in the policies in respect of AYUSH and allopathic treatment. Highlighting the service provided by AYUSH treatment during COVID-19 pandemic, the bench noted, "During Covid-19 pandemic, it is the traditional medicines that were recommended for the infected persons and the hospitals were only attending to emergency cases by providing support system, obviously, since allopathy did not have any medicine to treat covid-19 patients. It is true that such an eventuality would not have been anticipated at the time of finalizing the policy. That is the reason why the maximum cap was fixed under the policy. However, it came to light that the effective treatment was also given to the infected persons under AYUSH and it provided substantial relief to the patients. In such circumstances, it will not be reasonable to restrict the cap and thereby deprive the policy holders to get reimbursement of the amount, which was spent by them in AYUSH hospitals."

"The IRDAI must take into consideration the fact that patients can choose the type of treatment that is required for them and they have an option to either choose alopathic medicines or go for traditional medicines provided by AYUSH. Whatever expenses are incurred for either of these treatments must be placed on equal scales. It will be discriminatory to give preference to allopathy as against AYUSH treatment. This must be kept in mind by the third respondent whenever the policies are drafted and sent for approval," the Court further noted.

Directing IRDAI to draft future policies while giving equal importance to AYUSH treatment, the bench noted, "The third respondent must bear in mind that the traditional treatment in India which falls under the head of AYUSH treatment must also be encouraged and it must get the same weightage as is given to alopathic treatment and a person, who chooses to undergo AYUSH treatment should be entitled to receive the insurance amount towards the expenses incurred by him, as is done to a patient who undergoes alopathic treatment. This has to be implemented by the third respondent in all future policies."

At this outset, the bench recorded the submission by the Insurance Company that it has now come up with a new policy called as AYUSH plan policy, wherein even AYUSH treatment is covered and the expenses incurred for the treatment get reimbursed.

"By virtue of this new policy, AYUSH treatment has been brought on par with the alopathic treatment," noted the court while directing IRDAI to act upon the suggestion of the bench to place AYUSH treatment on par with Allopathic treatment and direct the insurance companies to reimburse the insurance amount on equal scales.

To read the order, click on the link below:

https://medicaldialogues.in/pdf_upload/madras-hc-reimbursement-227200.pdf

Also Read: HC upholds distinction between AYUSH, MBBS Doctors on basis of duties assigned for grant of honorarium