Reimburse cost of PPE kits: Ombudsman

The ombudsman concluded the insured could not be faulted for the charges levied for PPE kits, and the insurer would have to reimburse this amount

In recent times, hospitals have been flooded with patients. The cost of treatment has soared due to the need to use expensive medication and the need for the medical and para medical staff to change their personal protective equipment (PPE) multiple times. Insurance companies attempt to reduce their financial burden by disallowing the reimbursement of certain items such as PPE kits and bio medical waste. In a significant ruling, the insurance ombudsman has granted relief by asserting that these expenses have to be reimbursed by the insurer.
 
Jayaben Shah and her husband Ramniklal were insured under Jio’s group medical insurance policy issued by Universal Sompo General Insurance Co. They were covered for an amount of Rs 10 lakh for the period April 1, 2020 to March 31, 2021.

 
During the tenure of the policy, both Jayaben and her husband suffered from Covid 19. She was admitted to Harilal Jaichand Doshi GHS Hospital from October 1, 2020 to October 11, 2020. The cost of treatment came to Rs 1,51,239. When a claim was lodged, the insurer merely paid Rs 74,393, disallowing the remaining amount of Rs 76,846.
 

Similarly, her husband Ramniklal also suffered from Covid 19, for which he was admitted to the same hospital from September 25, 2020 to October 7, 2020. The cost of treatment came to Rs 1,54,262. When a claim was lodged, the insurer merely paid Rs 89,355, disallowing the remaining amount of Rs 64,907.

 
When questioned about the reason for not making full payment, the insurer clarified that the deductions were for proportionate deduction, certain non-payable items, and co-pay. Feeling aggrieved, Manish Shah, the son of Jayantiben and Ramniklal, filed a complaint before the insurance ombudsman for Mumbai and Goa.
 
After the complaint was lodged, the insurer agreed to reimburse the component deducted towards co-pay, that is, Rs 18,879 in the case of Jayaben Shah and Rs 26,170 in the case of Ramniklal Shah.
 
The insurance ombudsman sought clarification about the other deductions. The company clarified that the policy provided for capping of Rs 4,000 per day on room rent, so the charges billed in excess of Rs 4,000 would not be payable. The insurer also stated that Rs 5,500 towards bio-medical waste and Rs 10,200 for PPE kits were not payable.

 
Milind Kharat, the insurance ombudsman, in his order dated April 30, 2021, observed that the extra amount being billed for PPE kits was due to the pandemic. The patient neither had control nor was responsible for this increase in cost. Hence the ombudsman concluded that the insured could not be faulted for the additional charges levied for the use of PPE kits, and held that the amount billed by the hospital would have to be reimbursed by the insurer. Similarly, the amount deducted for bio-medical waste would also have to be reimbursed. However, the other deductions were held to be in order.

 
Accordingly, in the case of Jayaben Shah's claim, the ombudsman directed the insurer to reimburse Rs 10,200 for PPE kits, Rs 5,500 for bio-medical waste, and Rs 18,879 wrongly deducted towards co-pay. Similarly, in the case of Ramniklal Shah's claim, the ombudsman ordered the insurer to reimburse Rs 7,800 for PPE kits, Rs 6,500 for bio-medical waste, and Rs 26,170 wrongly deducted towards co-pay. A period of 30 days was given for the insurer to comply with the order.
 
The writer is a consumer activist