Insurance company directed reimbursement to doctor who was denied claim for surgery

Vadodara: The District Consumer Disputes Redressal Commission, Dohad recently directed an insurance company to pay Rs 58,675 to a doctor, who was denied a part of his claim from the insurance company for the surgical process he had to undergo in 2021.

The doctor had to approach the consumer court after being denied part of his claim. Ruling in favour of the doctor, the consumer court directed the insurance company to pay Rs 58,675 to the concerned doctor with an interest of six per cent.

Apart from this, he has also been granted Rs 1,000 by the consumer court for the agony he had to face. The court also directed the insurance company to pay another Rs 1,000 for legal expenses.

The matter concerned a physician from Dahod, who had to undergo surgery at a prominent hospital in Ahmedabad in August 2021. After the procedure, he remained admitted to the hospital for a day. 

He had to pay Rs 1.06 lakh on the surgery and after being discharged he demanded a claim for his treatment from the insurance company. However, the insurance company allowed only Rs 40,840 towards the claim. 

Also Read: Insurance company must reimburse compensation for negligence by doctors as per policy liability: Supreme Court

The company denied the remaining part of the claim stating that the complainant doctor did not submit the original receipt for a payment of Rs 30,000 in cash at the hospital. Further, an amount of Rs 28,675, which was spent towards hospitalization expenses, was denied by the insurance company, adds the Times of India.

Challenging this, the doctor approached the consumer court and stated that the original receipt had been misplaced and therefore he had obtained a duplicate receipt from the hospital and submitted the same against the claim.

While considering the matter, the Commission argued that the insurance company could have rejected the Rs 30,00 amount only if it had verified that it was not paid. It was observed by the consumer court that the duplicate receipt should have been accepted as a secondary evidence and the company should have cleared the amount. 

Further, the Commission observed that the hospitalization charges were denied on the grounds that there was no referral letter accompanying the documents for the expenses. 

Taking note of this, the Commission observed that the doctor submitted bills for the Rs 28,675 spent for these expenses made for investigations and diagnosis. At this outset, the consumer court further noted that the insurance company did not submit any evidence that could prove that this amount was wrongly claimed.

Therefore, granting relief to the doctor, the consumer court directed the insurance company to pay Rs 58,675 to the doctor with an interest of six per cent.

Medical Dialogues had earlier reported that while dealing with the question concerning a maximum limit of medical expenses set by the insurance company, the District Consumer Court, Vadodara recently observed that treatment expenses depend on the doctor, patient, and medicines used during the surgery. Therefore, the cost of every surgery is not the same and the Insurance Company cannot deduct the claim amount of the Insured by the reasoning that it is more than the maximum limit.

Also Read: Major Decision: Insurance company cannot set maximum limit on medical expenses, says Consumer court