Mumbai:
In a development, that would bring cheers to the health insurance policy holders,who are having Covid-19 treatment in big hospitals, Miland Kharat, Insurance Ombudsman, Mumbai & Goa, has directed Bajaj Alianz General Insurance,to pay one of its customer entire hospitalization expenses, barring non-medical items,incurred for Covid-19 treatment.
Abhay Chhapia, who had bought a health insurance policy from Bajaj Alianz General Insurance, with sum assured of Rs 30 lakh,, had availed medical treatment in Mumbai based Wockhardt Hospital for Covid-19.,
Afterwards, Chhapia had filed a complain, with the office Mumbai and Goa ombudsman, against short-settlement of a claim lodged under the policy for the said hospitalization by Bajaj Allianz General Insurance
Chhapia had complained that a claim lodged for Rs.3.1 lakhs for the treatment of Covid-19 (positive) undergone by him at Wockhardt Hospital was settled by the Bajaj Allianz General Insurance on cashless basis with a deduction of Rs.1.3 lakhs, almost half the amount of claim.
He stated that he has been associated with the company for many years.Chhapia had further argued that he, as an individual, has no say or bargaining power in front of the hospital and had to pay whatever amount was charged to him.
He had requested the office of Ombudsman for settlement of the balance claim amount.
After scrutinising the documents produced on record coupled with the depositions of both the parties, Kharat observed that the policyholder has taken treatment in the insurer’s network hospital. However, it appeared that the hospital has not adhered to Preferred Provider Networ (PPN) rates and has overcharged the patient in violation of their agreement with the Bajaj Allianz General Insurance .
“Nevertheless, it would not be fair to penalise the policyholder for the same as he has genuinely incurred the expenses and has paid the charges as billed by the hospital. We are of the view that the policyholder is entitled to be reimbursed the entire hospitalization expenses barring non-medical items and the Bajaj Allianz General Insurance may seek refund of the amount billed in excess of agreed rates directly from the hospital,'' said Kharat's order…
The award of insurance Ombudsman is binding on the Insurers.
Bajaj Allianz General Insurance had contended that the policyholder had lodged a claim for medical expenses of Rs.3,13,445 which was approved for an amount of Rs.1,52,039/-by deducting non-medical expenses and Rs.1,25,215 towards Clinical facilitation & safety, Clinical nutrition, Covid Hygiene, Covid waste management, Medical Registrar visit fees, Rehabilitation charges and excess PPE kit charges.
The Pune based genral insurer stated that they have already paid room charges of Rs.5,000 per day and housekeeping charges are not payable under any claim as per the terms & conditions of the policy.
Also, the policy provides for payment of Specialist’s fees but RMO(Resident Medical Officer) charges are not payable separately. They have paid Rs.650/- per Personal Protective Equipment (PPE) kit.