When it comes to prescribing a pathological test, the doctor’s decree is final, and don’t bother if the insurance agency argues otherwise. This was the drift of a landmark verdict that could provide relief to many medical policy-holders pursuing their claims.
A consumer court in the city has come to the aid of a middle-class family living near Dhakuria, that was told by the National Insurance Company that many of the diagnostic tests an old woman underwent were “unnecessary” and, so, not its concern.
The court told National Insurance to foot all the woman’s medical bills and ordered the firm to pay a monetary compensation of Rs 1,000 for “dragging the matter (on) such lame and insignificant grounds”.
Achintya Kumar Banerjee of Dhakuria made a Mediclaim policy for his parents, S.N. Banerjee and Hansi Banerjee, in 1995. Four year later, Hansi was admitted to a private hospital in Kasba, where the doctor asked her to undergo various tests, including an echo-cardiograph. The total bill came to Rs 9,117.
The claims were submitted to National Insurance soon after, but the firm was willing to pay only Rs 6,533. The firm said its empanelled doctors had probed the case and come to the conclusion that some of the tests (like ECG, USG and some other blood-tests) were not necessary, explaining the slash in the claim.
The Banerjees, with the help of a local consumers’ organisation, then went to the South 24-Parganas District Consumer Disputes Redressal Forum at Alipore. Opinion was sought from the Calcutta chapter of the Indian Medical Association (IMA).
The kind of “investigation required for a patient’s treatment is decided solely by the attending physician”, the IMA executive committee told the court. Since the doctor was “responsible and accountable” for the treatment, his/her decision could not be deemed “questionable”, it added.
The Banerjees’ legal team, armed with the IMA missive, told the court that the logic being put forward by National Insurance was “whimsical, unjust and could not be sustained”.
National Insurance legal representative N.R. Mukerjee told the court that his clients were laymen and were only acting in accordance with their doctors’ advice. There was no deficiency in service on the Mediclaim firm’s part, he added.
The court, however, ruled that the policy-holders were not supposed to know what test was relevant for the disease from which Hansi was suffering.