People often have to pay the additional portion of the surgery bill that the hospital handed over to them out of their own pocket. Now, because of this consumer court ruling insurance companies won't be able to impose restrictions on claim limits based on surgeries, the Times Of India reported. The Vadodara Consumer Commission, in a landmark decision, ruled that an insurance company cannot cap a customer's maximum medical expense limit and deduct that amount from the claim amount.
The commission noted this after reviewing the case brought forth by Chhani resident Pinkesh Patel, whose father needed cataract surgery, ToI reported.
In 2008, Patel purchased a Rs 3 lakh mediclaim floater policy from Oriental Insurance Company for his family. In May of this year, Patel's father had to have cataract surgery on his left eye, which cost Rs 41,237. When he submitted a claim for reimbursement, the insurance company only agreed to pay Rs 21,600, citing the cataract's maximum amount.
In June of this year, Patel subsequently lodged a complaint with the Vadodara District Consumer Disputes Redressal Commission (additional). In addition, he requested Rs 15,000 for each of the following: legal fees and psychological distress."Insurance company fixed claim limit."
According to the claim settlement letter Pinkesh Patel posted on the forum, he was eligible for a maximum payment of Rs 24,000 based on the credit limit, from which 10% would be withheld in accordance with the co-payment clause. The insurer maintained that it paid Rs 21,600 in accordance with the policy's terms and conditions. However, the commission decided that the insurer had not provided evidence of how the maximum limit amount was determined. The cost of the lens, the surgeon, the patient, and the medications used during the procedure all affect how much the treatment will cost. Every surgery has a different cost, according to the commission.
Therefore, the insurer, the opponent, cannot subtract the claim amount on the grounds that it exceeds the maximum limit. The commission further stated, "The opponent has engaged in unfair trade practices by deducting the claim amount," and it was mandated to pay Patel Rs 15,514 plus 9% interest. In addition, the forum mandated that the insurer reimburse Patel Rs 1,000 for legal fees and Rs 2,000 for mental harassment.