Wednesday, April 24, 2019

‘Insurance firm can’t decide line of treatment’

Only doctor and not the insurance company can decide the line of treatment to give to a patient. This observation was made by a consumer court here, which ordered the insurance firm and third-party administrator (TPA) to pay insured amount to a citizen. Complainant Bhanvarlal Purohit, owner of a farsan shop, claimed an insurance amount of Rs 19,457 after his wife Pushpa was discharged from hospital in January 2017. Pushpa was suffering from cervical spondyolis for which she underwent three-day hospital treatment.

A month later TPA Paramount Health Services and Insurance rejected Purohit’s claim on grounds that “no active line of treatment was given during hospitalization”. Purohit’s lawyer Montu Pandya said, “During hospitalization, the doctor prescribed tests, medicines and consulting a physician. But the firm claimed that such treatment was not needed to treat cervical spondylosis and therefore they rejected the claim.”

Purohit then approached the Vadodara District Consumer Disputes Redressal Forum in August 2018 against insurer National Insurance Company and the TPA. He submitted the discharge report along with doctor’s certificate that mentioned Pushpa’s health condition and the treatment offered to her. However, the court ruled that ‘No insurance company can decide the line of the treatment to be given to a patient, only doctors can decide about the treatment.”
The forum upheld the evidence and observed that the TPA has given its opinion after examining the case papers only. “Opinion of the doctor who treated patient is more truthful than the TPA’s opinion which is based on examination of case papers,” the forum stated.
The insurance has been asked to reimburse Bhanvarlal’s claim along with 8% interest and compensation of Rs 3,000.

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