The insurance company cannot refuse the mediclaim inclusive of MRI and pre-operation expenses simply because the policyholder had spent the amount a month before the surgery. The company must cover MRI and pre-operation expenses.
MUMBAI: Taking note of medical insurance firms constantly refusing mediclaim of patients on the various frivolous grounds, a recent consumer forum judgement put to rest one such dispute holding that pre-operation expenses including have to be reimbursed
The Maharashtra state panel under the presidentship of Justice A.P.Bhangale further specified that the expense incurred on Magnetic Resonance Imaging (MRI) scan, consultation, tests prior to the surgery cannot be denied to the policyholder. The insurance company cannot refuse the same simply because the policyholder had spent the amount a month before the surgery. The company must cover MRI and pre-operation expenses.
The judgment came after an aggrieved complainant appealed to the State forum against the New India Assurance Company Limited for refusing to reimburse a medical claim. The claim related to pre-surgery and non-medical expense (gloves for medical use) incurred for his son’s knee surgery.
In his complaint, Sridhar had mentioned that the medical claim policy covered his son, spouse and himself for Rs 1 lakh. Sridhar had lodged a claim of Rs 58,678. However, the company refused to honour the claim except to the extent of Rs 17,852. Later, when inquiries were made, claim in the sum of Rs 30,856 was approved by the company but it refused to award compensation for expenses prior to hospitalization and non-medical expenses. The patient was admitted to the hospital on April 18, 2012.
Subsequently, the panel passed orders stating that the medical claim was to the assured sum of Rs 1 lakh and the claim made by the complainant was much below the coverage amount. The claim was also supported by the documents and ought to have been allowed by the Insurance Company as the amount included fees of surgery as well as consultation charges, M.R.I. charges, gloves etc. The court further noted
M.R.I.test was necessary before surgery. Under these circumstances, insurer could not have refused to pay incidental and consequential expenses merely on the ground that surgery or M.R.I. were not within 30 days prior to actual hospitalization. In our view, consultation and pre-surgery test expenses cannot be refused merely on the ground that the complainant had spent the amount 30 days prior to the actual surgical operation.
The commission then ordered that the company will now have to pay the entire claim of Rs 58,678 along with compensation and litigation amount of Rs 15000 and Rs 5000 respectively. The company will further have to pay an amount of Rs 10000 as the cost of the appeal.