GUWAHATI: With the rising instances of cases being reported against insurance firms, a Guwahati resident recently won a case against a private health insurance firm which had failed to deliver a claim consistent to the policy purchased.
The resident, who requested anonymity, alleged that he had bought a medical insurance policy from Star Heath Insurance worth Rs 5 lakhs. He informed that the insurance companies have a certain capping in the policy for rooms rented in hospitals through the course of the hospitalization procedure.
“For instance, if you do buy a policy between Rs 1 lakh to Rs 4 lakhs, the room rent capping is Rs 5,000 per day. However, the catch is that if you take a hospital room which charges more than the capping limit provided by the insurance policy, your reimbursement amount will be paid after deducting the entire bill proportionately,” said the complainant.
He added that the deductions are made on every item in the bill that includes the doctor’s fees, operation costs and all other associated medical expenses. He said that usually the common people’s understanding is that they will have to pay the difference in the bill from their own pocket which is beyond the room rent capping as fixed in the policy. This doesn’t hold true here.
The complainant’s policy expired in April 2018 after which he had renewed it. However his policy was renewed according to the old policy norms where the room rent was fixed at Rs 7,500 but his new policy did not have any room rent capping.
“I took my wife to Chennai for treatment where we hired a room in the hospital at Rs 9,000 per day. So they cut down my bill by 33% at the time of claim, which was the difference according to the old policy,” he said.
The complainant’s bill came to be Rs 1.50 lakhs but he said he was paid only Rs 80,000 by the insurance company.
He then approached the grievance redressal system of Star Heath Insurance and put forth his complaint. However, they refused to refund the amount saying that it was part of the policy.
“After this, I approached the insurance ombudsman and they gave me a date and after hearing the case, the Ombudsman directed Star Health to pay me the rest of the amount which I received later,” the complainant told G Plus. He added that the insurance company lost the case on the ground that there was no room rent capping as they had removed the room rent capping clause for the policy from 2018.
He alleged that this system of reimbursing less by the insurance after deducting the bill proportionately is unfair.
“There is some sort of an understanding between the insurance companies and private hospitals. The insurance companies must be aware of the rent of the rooms available in different private hospitals in all cities and make their policies according to the current rate of room rent in different hospitals. This will be of great help to the consumers,” he said.
Consumer courts register maximum complaints against insurance firms
Complaints against insurance firms make for the maximum number of cases filed in the District Consumer Disputes Redressal Forum (DCDRF) in Guwahati, informed authorities.
“We see several cases against both public as well private insurance companies. Cases filed against insurance firms make up at least 30 to 40 per cent of total cases on an average, in a month,” informed member of DCDRF, Archana Deka.
Further, medical negligence cases are also filed frequently. These cases range from wrong diagnosis of diseases to negligence in medical services. Talking to G Plus, president of the DCDRF, Mohammad Sahadat Hussain, informed that such cases of medical negligence have become very frequent with at least three to four cases being filed with the consumer forum every month.
Hussain added that in a recent instance, a city resident had given his blood sample for testing to a laboratory before donating blood to a friend. However, the reports revealed that he had tested positive for HIV (Human Immunodeficiency Virus).
After this, the man consulted two doctors and on their advice, gave his blood samples for testing in two different laboratories. Both the results showed a negative result for HIV.
“He then filed a case of medical negligence against the first laboratory in which the DCDRF passed judgement and ordered the laboratory owner to pay compensation to the complainant,” informed Hussain.