Diabetics, especially those who are insulin dependent, have to monitor their blood sugar before every shot of insulin, to determine its correct dosage.This requires a glucometer and test strips, which are quite costly. Can the insured recover the cost under a mediclaim policy?
Case Study: Purvi Kamlesh Shah and her daughter were covered under a mediclaim policy issued by New India Assurance. The policy was first taken in 2005 and then renewed without any break. However, while renewing the policy with continuity, a fresh proposal form had been obtain in 2008.
During the tenure of the renewed policy from March 13, 2010 to March 12, 2011, Purvi had to be hospitalized on July 13, 2010 due to fluctuating blood glucose levels. After she was discharged on July 16, 2010, she lodged two claims, one for the hospitalization expenses of Rs 55,409 and the other of Rs 7,680 towards medicines. The insurer’s TPA, MD India Healthcare Services settled the claims at Rs 47,931 and Rs 3,680 respectively. The deductions were in respect of expenses incurred on purchase of glucometer strips to check the sugar levels. The reason for disallowance was that these were considered as “nonmedical expenses“, and so were not payable under the policy .
Purvi protested against this disallowance, but New India’s Grievance Cell failed to respond to her representation. She filed a complaint before the South Mumbai Forum through the Consumers Welfare Association and sought a direction to reimburse these expenses along with interest and also claimed compensation and costs.
The TPA as well at the insurer contested the case and claimed that the amount had been correctly computed. They claimed that Purvi was not entitled to dispute the amount after having accepted the claim in full and final satisfaction.
The forum observed that the policy conditions had been changed, so a fresh proposal had been taken in 2008. So the new terms under the revised policy would be applicable, which provided for limiting the claim on the basis of the room category. The forum concluded that there was no deficiency in service and dismissed the complaint. Purvi challenged the order, but her appeal was dismissed by the Maharashtra State Commission. Purvi then questioned the orders in revision. The National Commission noted that various clauses of the policy providing for certain exclusions had been inserted in the Mediclaim Policy (2007). The Commission observed that it was beyond comprehension how any claim for medicines could vary with the room category opted for, as medicines treatment would be the same regardless of the room category .
The Commission pointed out that glucometer strips are essential for a diabetic to monitor blood glucose levels and adopt a medical regime to prevent the consequences of elevated or declined blood sugar levels. So it would be wrong to consider the expense on the test to be nonmedical expenses. The deduction of Rs 9,350 on this pretext was held to be wrong.
The National Commission’s bench comprising of justice D K Jain, along with M Shreesha, held the TPA and the insurance company jointly liable to pay the cost of the test strips amounting to Rs 9,350 with interest at 9% from the date of filing of the complaint. Six weeks time was given for compliance of the order. In addition, costs of Rs10,000 were awarded to Consumers Welfare Association for espousing the cause of the consumer.
(The author is a consumer activist and has won the Govt. of India’s National Youth Award for Consumer Protection. His email is email@example.com)