Hyderabad: Insurer to refund patient who was denied claim

Hyderabad: The Hyderabad district consumer redressal forum has directed a health insurance company to reimburse a policy holder to whom it had withheld payment.

The complainant, Mr B.V. Ranga Rao, had a policy with Apollo Munich Health Insurance Co which provided him Rs 3 lakh cashless treatment. Mr Ranga Rao told the forum that he was suffering from multiple lipomatosis, the growth of fatty tissue under the skin on the body. It required the services of a plastic surgeon.

He approached Family Health Plan (TPA) Limited, the authorised agent of  Apollo Munich Health Insurance Co. Ltd, and took an authorisation letter from them to undergo the surgery. He joined the Krishna Institute of Medical Sciences (KIMS), Secunde-rabad, for cashless treatment.

The TPA’s authorisation letter approved treatment and guarantee of payment to the hospital. Mr Ranga Rao said the surgery was performed by a plastic surgeon but it was not plastic surgery. When he submitted the bills, the insurer rejected his claim. Apollo Munich after reviewing the documents and medical papers stated that the claim was “for management of ailment, which falls under the category of cosmetic / plastic surgery and any kind of cosmetic / plastic surgery is excluded in the policy”. The insurer contended that the complainant’s claim that though the surgery was performed by a plastic surgeon but it was not plastic surgery was incorrect.

Following this, Mr Ranga Rao said, he had to undergo agony and suffered tension as he had to arrange Rs 1,43,962 towards treatment. He then moved the forum.

The forum said that the company had not disclosed any ailment for which Mr Ranga Rao had undergone plastic surgery. “The burden to prove lies upon the insurance company, to establish that the complainant underwent plastic surgery,” the forum said and added that it had failed to do so.

The forum didn’t agree with the contentions of Apollo Munich and gave judgment in favour of Mr Ranga Rao. “As such there is deficiency of service on the part of the insurance company in repudiating the claim of the complainant for which they are liable for the same,” the forum said.  

The forum ordered Apollo Munich to reimburse a sum of Rs 1,43,962 which Mr Ranga Rao had incurred on medical expenses. It also ordered the company to pay interest at the rate of nine per cent per ann-um with effect from the date of denial of cashless services as well as costs of Rs 10,000.