Streamline Medical Insurance Claims Process: Delhi HC tells Govt

While giving the verdict, the bench acknowledged that such incidents of alleged harassment felt by the patients in settling their Final Bills are not an untold story but are frequently suffered by the patients. “Their harassment gets compounded by the fact that they come out of a trauma of an ailment under treatment, but even for discharge, there are long-drawn procedures for settling the bills with the Insurance Company. This harassment and mental trauma by the patients and their family members who are pushed to follow the matter with the Insurance Company for getting the requisite approvals which is riddled with delays at the end of the Insurance Companies, is well understandable.”

The Petitioner, who was diagnosed with Cysticercosis of the right hand, chose to get himself operated at the Max Hospital. He was holding a Cashless Insurance Policy from Max Bupa Health Insurance Company Ltd. and which was covering Max Hospital as one of its Network Hospitals. The Petitioner decided to get his surgery performed under the Cashless Scheme, which required pre-authorisation from the Insurance Company and Despite the authorisation under the Cashless Policy, the petitioner was asked to deposit the entire estimated amount before surgery. Despite the protest, he was forced to deposit an advance sum of Rs. 1,45,000 and surgery was conducted after. After the surgery, he was not allowed to be discharged till the entire payment was received from the Insurance Company.

At the time of discharge, a bill of Rs. 1,73,906.94 was prepared. Despite being entitled to a discount of Rs. 12,495, the same was not adjusted in the initial Bill by the Patient Care Co-Ordinator, but it was later adjusted. The petitioner alleged that the approval from the Insurance Company of the entire amount was received but the hospital claimed that they had only received an amount of Rs. 1,04,080, and the Petitioner was forced to pay Rs. 57,332 for his discharge.

The petitioner claimed that the amount was unauthorizedly debited by the Hospital from his advance deposit, and the pre-deposit was entrustment of money to the Max Hospital, which was misappropriated by the Max Hospital, by failing to refund the entire sum to the Complainant and thereby, offence under Section 406 of IPC was also committed. Furthermore, he was wrongfully confined in the hospital and was given a timely discharge despite the fact that he had a cashless policy. Hence, an offence of Wrongful Restraint punishable under Section 342 of the Indian Penal code (IPC) was also levied against the hospital.

After the pursual of arguments and reports, the court noticed that when the Petitioner approached Max Hospital, the charges were stated to be Rs. 2,20,316 for a single occupancy room while the cost of a shared room was Rs. 1,79,368. The Petitioner chose to avail the higher room (Deluxe room facility) for which the charges were Rs. 2,20,316. The Insurance Policy was only in regard to the Standard Room, but the facilities availed by the petitioner were for a Deluxe Room; there was a balance of Rs. 57,332, which was payable and was accordingly adjusted from the amount deposited by him.