In a growth that might convey cheers to the medical insurance coverage holders, who’re present process Covid-19 remedy in large hospitals, Milind Kharat, Insurance Ombudsman, Mumbai & Goa, has directed Bajaj Allianz General Insurance, to pay one among its clients your complete hospitalization bills, barring non-medical gadgets, incurred for Covid-19 remedy.
Abhay Chhapia, who had purchased a medical insurance coverage from Bajaj Allianz General Insurance, with a sum assured of Rs 30 lakh, had availed of medical remedy in Mumbai primarily based Wockhardt Hospital for Covid-19.
However, Chhapia had filed a criticism with the Ombudsman towards short-settlement of a declare lodged beneath the coverage by Bajaj Allianz General Insurance. He complained {that a} declare lodged for Rs 3.1 lakh for the remedy of Covid-19 (constructive) undergone by him at Wockhardt Hospital was settled by Bajaj Allianz General Insurance on cashless foundation with a deduction of Rs.1.3 lakh virtually half the quantity of declare.
He said that he has been related to the corporate for a few years and additional argued that he, as a person, has no say or bargaining energy in entrance of the hospital and needed to pay no matter quantity was charged to him.
After scrutinising the paperwork produced on document coupled with the depositions of each the events, Kharat noticed that the hospital has not adhered to Preferred Provider Network (PPN) charges and has overcharged the affected person in violation of their settlement 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,” Kharat’s order stated.
The award of insurance coverage Ombudsman is binding on the insurers.
In a press release, Bajaj Allianz General Insurance stated, “the insured had approached us for cashless claim which was approved within agreed SLA and as per policy T&C. The Ombudsman directed us to pay balance admissible claim amount barring the non-medical expenses. On further scrutiny we identified Rs 6,897 was inadvertently missed (comprising Rs 6,000 towards dietary charges deducted, Rs 640 towards IV Canula, Rs. 250 towards Emergency rent and Rs 7 towards Blood Safety Lancet Sd Biosensor) barring the non-medical expenses (NME) which we have paid to the customer and informed the Ombudsman accordingly. The rest of the NME deductions were as per IRDAI approved list of NME charges.”
“Overall, we have paid additional Rs 6,897 as per Ombudsman award against the relief sought by customer of Rs 1,22,885,” the corporate stated.
According to the Ombudsman, the corporate had contended that the policyholder had lodged a declare for medical bills of Rs 313,445 which was accepted for an quantity of Rs 152,039 by deducting non-medical bills and Rs 125,215 in the direction of scientific facilitation & security, scientific vitamin, Covid hygiene, Covid waste administration, medical registrar go to charges, rehabilitation prices and extra PPE package prices.
“The respondent 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 PPE kit,” Ombudsman stated.
