Kochi: The Consumer Disputes Redressal Forum, Ernakulam, came down heavily on the “unholy alliance” between hospital establishments and medical insurance companies to deny legitimate and genuine claims of consumers for reimbursement of hospital bills covered by valid insurance policy.
Pointing out that instances of unjustified repudiation of insurance claim by insurance companies is on an increase, going by the statistics of the cases of such nature, being filed before it, the Forum headed by Cherian K Kuriakose noted, “from proved evidence, a doctor who belongs to the noble profession has become a prey at the hands of dishonest employees of corporate, by stage-managing a per se forged document, presumably with dishonest intention to gain undeserved enrichment at the cost of denying a merited and genuine claim of the complainant”.
The Forum was hearing the case of a 11-year-old boy, who underwent treatment at a private hospital in Kochi from October 22 to 29, 2014 for acute bronchial asthma. The total cost of the treatment was Rs 41,414.39 and the same was covered by a medical insurance policy. The boy’s father paid the said amount and then submitted documents to the insurance company for settlement.
But after keeping the claim on hold for long, the insurance company informed that they were ineligible for settlement stating that the treating doctor had certified that the patient was wheezing since five months of age. It was also alleged in the repudiation letter that the existence of asthma ailment was known to the child’s father and he did not declare it at the time of entering into the insurance contract.
After going into the details of the case and hearing both parties, the Forum in its order said that private hospital doctor had issued the medical certificate detrimental to the patient without referring to the patient’s previous history or medical record available at the hospital, purely on the basis of hearsay information and without supporting documents. “The opposite parties have committed unfair trade practice and deficiency in service against the complainant,” the forum in its order observed.
To keep a check on such professional misconduct and unethical medical practices, the Forum has referred the matter to TCMC for taking appropriate necessary action against the erring doctor. A copy of the order shall be sent to the state principal secretary and IMA, Ethics Committee, for appropriate action after due enquiry. The private hospital has been directed to pay Rs 10,000 towards the unfair trade practice committed against the complainant.
Meanwhile, the insurance company has been directed to reconsider the claim application within a month. The forum added that the complainant is entitled to get Rs 1 lakh towards the mental agony and uncertainty in a genuine claim.