In the recent past, insurance companies short listed some of the hospitals from their panel and objected to their prescribing a number of laboratory tests, and recommending costly treatments and operations which insurance companies thought could be avoided. Subsequently insurance companies stopped cashless facilities in some of these private hospitals. But there was sharp retaliation to such move, and courts through various judgments warned the insurance companies not to step into the shoe of doctors.Maharashtra State Consumer Dispute Redressed Commission has shown insurance firms their place, directing that it is the doctor and not the insurer who can decide whether a case requires emergency medical attention or not. It is further stated that “insurance company’s officers are not experts who can decide whether a particular case is of medical emergency or not.”

“it is the doctors who decide what treatment is required to be given. Once the insured has paid the agreed amount of premium, insurance company is bound to meet the expenses”held  in  Shamim Khan V New India insurance company, Maharashtra State Consumer Dispute Redressed Commission,2000.

 

[Facts of the case;- Shamim Khan, the plaintiff who was working as a school teacher in Saudi Arabia suffered unbearable stomach pain when he visited India in July 2000, which led to severe bleeding. Khan was admitted to Bombay hospital where emergency surgery was conducted. Claim for total expenditure of Rs 41,158 was rejected on the plea that there was no emergency to undergo operation. Doctor’s certificate was then produced to prove the emergency in the case.

Apart from directing the claim of the consumer to be paid, court also fined the insurer Rs 5000 for rejecting the claim. The order came at a time when insurance companies are desperately trying to avoid passing claims and reimbursing expenses, borne by the insured under mediclaim policies. It is surely a big relief to the consumers at this juncture. ]

A study of medical trade practices in Mumbai sponsored by World Health Organization reveals the unethical and illegal trade practices of doctors and drug companies. Pharmaceutical companies sponsor Continuous Medical Education [CME] camps, where they develop personal bonds with the doctors, which they further strengthen with sponsored cocktail parties and then overseas trips. The net result of such favour ultimately burdens the patients admitted in the hospitals who are prescribed drugs from specific companies that may be much costlier than other brands available outside.

IRDA.Guidelines 6th January,2011

Some companies started enhancing their premium amount for senior citizens with a view that after certain age, their medical expenses do increase. But now this controversy is also settled and IRDA on 6th January2011 has asked insurance companies to refrain from charging policy holders the premium amount which is outside the range filed with IRDA.

This change in the attitude is surely the result of various judgements pronounced by the courts in favour of consumers

 

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