Insurance Ombudsman disallows Cataract Surgery claim for multifocal lens

Complaint No. I.O.(HYD) G -11.51.0100 / 2017-18
Mr. P. Satyanarayana VS. United India Ins. Company Ltd.
Award No. I.O. (HYD)/A/GI/0013/ 2017-18

Insurance Ombudsman Date of award : 11.08.2017

GROUP MEDICLAIM

FACTS
The complainant, Sri P. Satyanarayana, a retired officer of SBH, preferred claim for cataract surgery under Tailor-made Group Mediclaim Policy taken by SBH through Indian Banks Association. He incurred Rs.65,800/- towards right eye cataract surgery at Dr. Harikishan Eye Care Hospitals, Hyderabad. The TPA approved Rs.40,000/- towards cashless treatment. The balance amount of Rs.25,800/- was paid by the complainant and later preferred claim for reimbursement. The claim was rejected by the Insurer for the excess amount collected by the hospital from the complainant.

FINDINGS
The complainant stated that the hospital estimated the cataract surgery cost at Rs.65,800/-. The servicing TPA approved the surgery for Rs.40,000/- only and the remaining amount of Rs.25,800/- was paid him. The insurer submitted that the insured person underwent RE Cataract Surgery on 23.12.2016 and TPA received pre-authorization request from the hospital for Rs.40,000/- and the authorization form was also signed by the complainant. The TPA gave authorization for the same amount and on discharge the hospital sent final bill for Rs.40,000/- which included OT charges, Phaco charges, Anesthetist charges, Surgeon charges, Foldable IOL charges, OT drugs, disposables, room rent and nursing charges. Subsequently, the complainant filed a reimbursement claim for Rs.25,800/- on 13.01.2017 for the same hospitalization/surgery and for the same charges. The hospital raised another bill to recover the multifocal lens cost since the complainant opted multifocal lens. The complainant instead of going for normal cataract surgery of monofocal lens which would have rectified his vision and restored his normal eyesight, gone for a premium multifocal cataract surgery. Hence, reimbursement claim was rejected under policy clause 1.1, 1.2 & 2.34 of the policy.

DECISION
The complainant stated that as he was suffering from ‘Anxiety neuroses’ the doctor advised him to go for multifocal lens had gone for multifocal lens and claimed the balance amount. Since the insured opted for multifocal lens, the extra amount was charged by the hospital to the insured. The hospital raised two separate bills for same surgery. Out of two bills presented the one for Rs. 40,000/- was approved for cashless by TPA and the second bill was denied on the ground that multifocal lens cost does not fall under customary charges. The second bill does not contain Lens charges. On being questioned about any proof of recommendation of multifocal lens by the treating doctor he referred to a certificate issued by the treating doctor but that does not speak about any recommendation for multifocal lens. Hence, the complaint is dismissed.