Insured cannot claim same expense twice

Vijander Bhandari, a retired army colonel, was a member of the Ex-Servicemen Contributory Health Scheme (ECHS). He was also covered under an individual health insurance policy of Rs 2 lakh obtained from ICICI Lombard. Bhandari developed acute chest pain on February 2, 2016, for which he was admitted to Sir H N Reliance Foundation Hospital in Girgaon, Mumbai. He underwent an open heart surgery the next day under Dr Sudhansu Bhattacharyya. At the time of discharge on February 14, 2016, the hospital issued a final invoice of Rs 4,53,033 as well as a separate bill of Rs 6 lakh issued by Dr Sudhansu Bhattacharyya towards his fees. The total amount came to Rs 10,53,033.

Bhandari first lodged a claim with ICICI Lombard. Since the medical expenses exceeded the sum insured, ICICI paid Rs 2 lakh, which was the maximum coverage available under the policy. Bhandari then applied to the ECHS for the balance amount of Rs 8,53,033. However, he was paid only Rs 73,133.
 

Bhandari sent representations for the remaining amount, but ECHS did not respond. The Secretary of the Ex-Servicemen Welfare Department also requested the ECHS to look into Bhandari’s grievance. Thereafter a further claim of Rs 1,75,506 was sanctioned while rejecting reimbursement of Rs 6 lakh paid as fees to Dr Sudhansu Bhattacharyya.
 

Bhandari filed a complaint before the Consumer Commission, South Mumbai District, contending that ECHS was wrong in denying reimbursement of the surgeon’s additional fees of Rs 6 lakh. ECHS argued that according to its rate list published on July 9, 2002, a limit of Rs 1,48,500 had been prescribed for coronary bypass surgery, and hence Bhandari was not entitled to claim any further amount.
 

After considering the rival contentions, the District Commission allowed the complaint and ordered payment of the remaining amount of Rs 6 lakh paid towards the surgeon’s fees.

The ECHS appealed against this decision to the Maharashtra State Commission which set aside the order and held that the claim of Rs 6 lakh had been rightly repudiated. Bhandari now challenged this decision by filing a revision petition before the National Consumer Disputes Redressal Commission. His main argument was that there was no dispute over the amount of Rs 6 lakh having been paid to Dr Sudhansu Bhattacharyya for the surgery, so the refusal to reimburse this amount was not justified.
 

The National Commission observed that the hospital bill of Rs 4,53,033 was for a “CABG Package” which included a doctor’s fee, surgeon’s fee, as well as an anaesthetist’s fee. This amount had been reimbursed under ICICI’s Individual Mediclaim Policy and ECHS. The only dispute was whether the additional fees of Rs 6 lakh charged by Dr Sudhansu Bhattacharyya should be reimbursed or not.
 

The National Commission observed that since the settlement of the claim according to the hospital bill covered the surgeon’s fees, it would be incorrect to order reimbursement of additional fees for the same surgery merely because the surgeon had raised a separate bill. So, the Commission concluded that even though Bhandari had paid the bill for the additional amount, he would not be entitled to seek reimbursement.

The National Commission concluded that reimbursement for the same head of expense, namely surgeon’s fees, cannot be claimed twice. Accordingly, by its order of November 1, 2023, delivered by Inder Jit Singh, it dismissed Bhandari’s revision petition.

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The writer is a consumer activist