Streamline Medical Insurance Claims Process: Delhi HC tells Govt

The bench observed that many courts have recommended that there may be some Regulatory Policy and even a Charter of Patients' Rights, which NHRC has proposed, but unfortunately, no final redressal to this aspect has been worked out to date.

A bench of Justice Neena Bansal Krishna was considering a plea by a lawyer who alleged cheating, fraud, wrongful retention, and mental harassment against Max Hospital, Saket. However, the court observed that there have been no criminal offences on the part of the hospital. “Much angst has been expressed on this system of getting the approvals from the Insurance Company at many forums and by the Courts, but such a situation may be a ground for seeking compensation for mental harassment, but does not tantamount to any criminal offence,” stated the bench.

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.

Moreover, the pre-authorisation from the Insurance company was received for Rs. 75,000, and consequently, the Max Hospital made the Petitioner deposit the remaining balance of Rs. 1,45,000 since on the date of admission, there was no approval for the amount. “It may seem to be an onerous condition, but it can definitely not be stated to be the extraction of money nor can any dishonesty or fraudulent intention be attached to the Max Hospital, in this regard,’ the bench stated.

As far as unlawful constraint is concerned, the bench observed that there was a delay in discharge from the Max Hospital on account of the requisite approvals to come from the Insurance Company, because approvals from the Insurance Company took some time. “The circumstances do not establish that there was any intentional wrongful restraint, but it was only the procedural delay and no offence under Section 342 IPC,” stated the court.

Upholding the session court’s judgement, the bench disposed the petition stating, “Whatever was the amount deposited in the Max Hospital as advance, was understood to be adjusted at the time of final Bill, which had been done. There is no misappropriation of funds by the Max Hospital and no offence under Section 406 IPC, is made out.”

To view the official order, click on the below link: