Insurance Ombudsman rejects insurance claim for unjustified surgeons fees

Complaint No. I.O.(HYD) G -11.51.0074 / 2017-18
Mr. K.V. Subrahmanyam VS. United India Ins. Company Ltd.
Award No. I.O. (HYD)/A/GI/0002/ 2017-18

Insurance Ombudsman Date of award:10.08.2017

GROUP MEDICLAIM

FACTS
The complainant, Sri K V Subrahmanyam, a retired officer of State Bank Of Hyderabad was covered under a Group Mediclaim Policy taken by the Bank with the insurer from 01.11.2016 to 31.10.2017. He underwent TURP surgery at KK Hospitals, Vijayawada from 29.01.2017 to 02.02.2017 and incurred Rs. 74,419/- for the surgery. The insurer/TPA settled the claim for Rs.41,629/- and deducted Rs.32,790/- of which Rs.30,000/- related to the surgeon’s fee. He represented to the insurer to review the decision as the surgery charges were unreasonably deducted without any valid reason. There was no further revision in the settlement.

FINDINGS
The complainant contended that while settling the claim the servicing TPA unreasonably deducted Rs.30,000/- from the surgeon charges and allowed only Rs.15000/- on the alleged ground that the surgeon charges was in excess. Though there were other deductions amounting to Rs.2,790/- his prime concern relates to the surgeon charges which was unreasonably settled for only Rs.15000/- by the TPA/Insurer. It was strongly contended by the insurer that the hospital unreasonably charged Rs.45000/- towards surgeon charges. For the same procedure, in Vijayawada other hospitals, which are of equal quality by all means, charge less than Rs.15,000/- towards surgeon’s fee. In this connection the servicing TPA ‘Paramount Health Services (TPA) Pvt. Ltd.’ Vide their letter dated 18.07.2017, furnished package rates agreed by 4 hospitals which had similar infrastructure facilities in Vijayawada. M/s Kamineni Hospitals, Vijayawada charges Rs.48,750/- for TURP procedure and the surgeon charges are only 25% to 30% of the total bill which is around Rs.12,000/- only. M/s Vijay Super Speciality Hospital, Vijayawada charging a package rate of Rs.25000/- for TURP procedure excluding implants for which is surgeon charges are around Rs.10,000/- only. M/s Vijayawada Multispecialty Hospital, Vijayawada charges package rate of Rs.36,000/- for TURP procedure for which surgeon charges are around Rs.10,000/- only. M/s Lifeline Hospitals Trimurthy Center, Vijayawada charges, for major surgeries like TURP, only Rs.10,000/- towards surgeon’s fee. Hence, the deduction of Rs.30,000/- was justified under the policy clause 1.1 read with clause 2.33 ‘Reasonable & Customary charges’.

DECISION
They have submitted to the forum the package rates prevailing in and around the vicinity of the same hospital of similar quality and infrastructure where the insured patient underwent surgery. Thus on perusal of the bill the forum finds that the surgeon fees alone is more than 60% of the total which is not in conformity with the prevailing rates. The insurer is justified in reimbursing as per policy condition only the reasonable and customary charges which they proved with documentary evidence. Hence, the complaint is dismissed.