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Insurance firms told to pay Rs 27k for failing to provide cashless treatment
The Times of India May 16, 2019

The district consumer disputes redressal forum directed the New India Assurance Company and Vidal Health Insurance TPA to pay Rs. 15,000 as compensation for failing to provide cashless treatment despite promise and not paying the full claim to the complainant. They were also directed to pay the remaining claim of Rs. 12,042 along with 9% interest per annum from the date of making the first payment i.e. December 4, 2017, till realization.

Sunita Bhalla, a resident of Sector 4, Panchkula, stated in her complaint that her husband had purchased New India Flexi Floater Group Mediclaim Policy from the company. She got unwell and was admitted to a private hospital in Mohali on October 6, 2017, and was discharged the next day.

The hospital had raised a bill of Rs. 1.29 lakh which was paid by them as the insurance company did not accord approval for cashless treatment, though the policy of cashless treatment was taken.

The bill was submitted to Vidal and an amount of Rs. 99,632 was only transferred to her account and when she sent a legal notice to the New India Insurance Company further amount of Rs. 15,025 was transferred to her account without any reference but the remaining amount of Rs. 15,292 was not transferred from the total amount of Rs. 1.29 lakh. Despite cashless policy, approval was not accorded. Since no approval was received, the complainant was put to humiliation.

In its reply, the insurance company stated that deductions were made as per terms and conditions. There was capping in the room rent and was limited to boarding and nursing expenses actually incurred or 1% of the sum insured per day whichever was less,. Rs. 1,500 as against admission charges, Rs. 168 deducted against consultation charges, Rs. 350 deducted as against consumables and disposables, Rs. 1,836 deducted being non-medical expenses, Rs. 492 deducted against laboratory investigation, Rs. 1,275 deducted against miscellaneous charges, Rs. 500 deducted being excess amount and Rs. 19,960 was deducted against charges of surgeons.

Vidal did not reply to the notice.

The forum after hearing both the sides held; “Perusal of the recod shows that the first installment of Rs. 99,632 was deposited in the account of the complainant and thereafter another amount of Rs. 15,025 was deposited in her account. How this was released in piecemeal is not understandable and no clarification on this score has been given by the companies.

It was further pointed by the forum, headed by president Rattan Singh Thakur, that “The insurance company has not denied the claim that it was a cashless facility. If it was so, then why approval was not accorded for cashless facility, is not understandable.”

The forum observed that: “Even the evidence led by the complainant shows when the assurance of approval for cashless facility was given by them, the hospital had calculated the patient’s share of Rs. 3,250 and the rest was cashless. There is no explanation on this point of fact why the approval for cashless facility was not accorded particularly when the policy was such. The insurers themselves did not follow the terms and conditions of cashless facility. At the most, Rs. 3,250 as parient’s share could have been deducted and no other amount.”

They were then directed to pay up for causing mental agony and harassment to her.

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