A patient is entitled to get reimbursement of durable equipment used for medical treatment after getting discharged from the hospital. Vijay Joshi had filed a complaint against the National Insurance Company Ltd that accepted only a partial insurance claim citing that the BiPAP machine isn’t covered by the policy.
According to a Vadodara consumer forum gave this judgment, while hearing the case of Joshi, a resident of Alkapuri.
Joshi, a senior citizen, was admitted to a private hospital in October 2021 and he was diagnosed with a disorder similar to sleep apnea. He lodged an insurance claim of Rs 1.13 lakh, but the insurance firm transferred only Rs 33,837 to his account.
The insurer argued that all the external durable equipment which can be used at home including the CPAP are excluded under a certain clause of the policy, bought by Joshi, who then filed a complaint in the Vadodara District Consumer Disputes Redressal Commission (additional) in December 2022.
The complainant said that he was suffering from nasobronchial hyperactivity, obstructive airway disease, obesity hypoventilation syndrome (OHS), and the said condition if not treated early may be effectively life-threatening.
He also said to manage smooth breathing of OHS patients, use of the BiPAP machine – a life-saving device – is essential. Joshi said in the forum he was advised by the medical professional to take BiPAP during the discharge from the hospital and thus the machine was an integral part of the treatment. He also said that he wasn’t supplied or explained the terms and conditions of the policy.
The forum noted the words ‘items that are subsumed into costs of treatment’ that was a part of the lists in the policy and observed that BiPAP machines are to be included in the cost of treatment.
Taking a note of the hospital’s discharge summary and advice of using BiPAP, the forum said, “Thus the indoor hospitalization was to culminate into a definite treatment thereafter and even at home. Therefore, it should have been considered as the cost of hospitalization treatment.”
The forum further added that a clause in the policy also permits post hospitalization expenses incurred 60 days immediately after the insured person is discharged from the hospital.
The consumer forum ordered the insurer to pay Rs 79,562 with nine per cent interest to Joshi apart from Rs 3,000 for mental agony and Rs 2,000 towards the legal costs.
