Retired judge Ashim Banerjee, chairperson of the commission, said the insurer's complaint named one hospital in Calcutta, one in Durgapur and two in Siliguri. All four hospitals have since submitted written responses to the allegations.
"We have received a written complaint from a private insurance company against four private hospitals. The insurer has provided four sample cases that it claims involved fraudulent transactions. Though the hospitals replied only on those bills, we are treating this as a broader issue," Banerjee said, reports The Daily.
The insurer alleged that patients were hospitalised even when admission was not medically warranted, that stays were extended well beyond clinically necessary durations, that single surgical procedures were split into multiple bills to inflate charges, and that medical records had been altered to justify the billing pattern.
In a related development, the commission directed a Calcutta hospital to refund ₹58,000 to a patient who had paid the amount out of pocket after the insurer declined to settle a portion of the bill.
While the hospital contended that the claim had been wrongly denied, the commission held that the dispute should have been taken up directly with the insurer rather than recovered from the patient.
As per a report by Telegraph India, the commission also heard a complaint on Wednesday in which a patient's family was asked to pay an amount the insurer refused to reimburse. The surgery cost was more than twice the hospital's estimate. The patient had insurance cover of ₹5 lakh.
Banerjee said the hospital had billed ₹4.21 lakh, of which the insurer paid only ₹2.64 lakh. Questioning the hospital's stance, he asked why charges were levied for treatment components the insurer had deemed non-payable, adding that the institution should have pursued the matter with the insurer rather than recovering the balance from the insured patient.
The hospital, for its part, maintained that the rejected portion of the claim had been wrongly disallowed by the insurer.
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