In­surer to re­fund pa­tient who was de­nied claim

Deccan Chronicle - - City - DURGA PRASAD SUNKU | DC

The Hy­der­abad dis­trict con­sumer re­dres­sal fo­rum has di­rected a health in­sur­ance com­pany to re­im­burse a pol­icy holder to whom it had with­held pay­ment.

The com­plainant, Mr B.V. Ranga Rao, had a pol­icy with Apollo Mu­nich Health In­sur­ance Co which pro­vided him `3 lakh cash­less treat­ment. Mr Ranga Rao told the fo­rum that he was suf­fer­ing from mul­ti­ple lipo­mato­sis, the growth of fatty tis­sue un­der the skin on the body. It re­quired the ser­vices of a plas­tic sur­geon.

He ap­proached Fam­ily Health Plan (TPA) Lim­ited, the au­tho­rised agent of Apollo Mu­nich Health In­sur­ance Co. Ltd, and took an au­tho­ri­sa­tion let­ter from them to un­dergo the surgery. He joined the Kr­ishna In­sti­tute of Med­i­cal Sciences (KIMS), Se­cun­der­abad, for cash­less treat­ment.

The TPA’s au­tho­ri­sa­tion let­ter ap­proved treat­ment and guar­an­tee of pay­ment to the hospi­tal. Mr Ranga Rao said the surgery was per­formed by a plas­tic sur­geon but it was not plas­tic surgery. When he sub­mit­ted the bills, the in­surer re­jected his claim. Apollo Mu­nich af­ter re­view­ing the doc­u­ments and med­i­cal pa­pers stated that the claim was “for man­age­ment of ail­ment, which falls un­der the cat­e­gory of cos­metic / plas­tic surgery and any kind of cos­metic / plas­tic surgery is ex­cluded in the pol­icy”. The in­surer con­tended that the com­plainant’s claim that though the surgery was per­formed by a plas­tic sur­geon but it was not plas­tic surgery was in­cor­rect.

Fol­low­ing this, Mr Ranga Rao said, he had to un­dergo agony and suf­fered ten­sion as he had to ar­range `1,43,962 to­wards treat­ment. He then moved the fo­rum.

The fo­rum said that the com­pany had not dis­closed any ail­ment for which Mr Ranga Rao had un­der­gone plas­tic surgery. “The bur­den to prove lies upon the in­sur­ance com­pany, to es­tab­lish that the com­plainant un­der­went plas­tic surgery,” the fo­rum said and added that it had failed to do so.

The fo­rum didn’t agree with the con­tentions of Apollo Mu­nich and gave judg­ment in favour of Mr Ranga Rao. “As such there is de­fi­ciency of ser­vice on the part of the in­sur­ance com­pany in re­pu­di­at­ing the claim of the com­plainant for which they are li­able for the same,” the fo­rum said.

The fo­rum or­dered Apollo Mu­nich to re­im­burse a sum of `1,43,962 which Mr Ranga Rao had in­curred on med­i­cal ex­penses. It also or­dered the com­pany to pay in­ter­est at the rate of nine per cent per an­num with ef­fect from the date of de­nial of cash­less ser­vices as well as costs of `10,000.

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