• Covid claim settlement

I have filed a claim for Covid hospitalization of which only 10 percent of the amount has gotten settled.( 27000 against 200000) HDFC ergo is saying that this is as per govt notification.
But if there were caps then the hospital should have not charged so much . Do I have any legal recourse to take this matter further
Asked 11 months ago in Consumer Law

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13 Answers

Ask HDFC ergo to furnish copy of govt notification that lays down cap for hospital charges 

 

2) complain to IRDA against HDFC ergo failing to pay your hospital expenses 

 

3) complain to state govt against exhorbitant bills charged by private hospital and to direct hospital to refund excess amount charged 

 

4) if necessary file complaint against hospital and insurance company before consumer forum and seek orders to direct hospital to refund excess charges . In alternative to direct insurance company to pay hospital charges 

Ajay Sethi
Advocate, Mumbai
84068 Answers
5480 Consultations

5.0 on 5.0

File complaint under Section 35 of the Consumer Protection Act,2020. I have filed a similar claim in Delhi.

Sumit Rana
Advocate, New Delhi
19 Answers

Not rated

Check the insurance policy terms first to see whether there is any limitation for reimbursement or actual expenditure to be reimbursed.

Everything will be regulated as per terms of the policy agreement. 

Kallol Majumdar
Advocate, Kolkata
2800 Answers
7 Consultations

5.0 on 5.0

The expenses pertaining to hospitalization are 'incurred' expenses whereas the mediclaim is an accrued settlement of amount that you may get reimbursed with post incurring of such hospitalization expenses. 

In your case if hospital has concealed the charges towards hospitalization or has misrepresented before you by stating that the entire hospitalization charge would be covered through your mediclaim, then only you can take recourse against hospital. Other than this there is hardly any scope of claim against hospital. 

So far as HDFC ERGO is concerned, it is advisable for you to verify the contents of your policy and cover under which  your medical expenses would be reimbursed. 

In Ref: IRDAI/HLT/REG/CIR/054/03/2020 issued by Central Government there is no such cap on reimbursement.

Pooja Ashar
Advocate, Ahmedabad
215 Answers
2 Consultations

5.0 on 5.0

File  complaint before district consumer forum against hospital and Insurance company. 

Mohammed Mujeeb
Advocate, Hyderabad
19011 Answers
28 Consultations

4.5 on 5.0

Hi, First you can issue legal notice and thereafter, you can file a complaint before the District Consumer Court.

Pradeep Bharathipura
Advocate, Bangalore
5135 Answers
282 Consultations

4.5 on 5.0

You may first go through the conditions for this claim.

If the conditions do not restrict your claim to this minimal reimbursement, then you may first issue legal notice to the insurer demanding the balance amount citing the conditions.

You may pursue the matter through consumer forum if at all you are eligible for a higher amount than what has been paid to you.

You may first how the papers and the insurance policy to an advocate before taking any legal action, obtain legal opinion and proceed if recommended.

.

 

T Kalaiselvan
Advocate, Vellore
74174 Answers
1203 Consultations

5.0 on 5.0

Insurance Company has insured your prior to any such capping order or circular and what is effect of the capping and circular ver the claim of the party over the insured expenses which are actually incurred by you,

In my considered opinion you should proceed taking legal resources agains the insurance company and hospital in appropriate forum for recovery of expenses incurred by you and damages thereon.

Arihant Nahar
Advocate, Indore
125 Answers

4.8 on 5.0

Dear Client, You should get checked the notification he is referring to and then proceed accordingly.

 

Anand Shukla
Advocate, New Delhi
666 Answers
13 Consultations

4.9 on 5.0

You need to first study the circular and your claim coverage. If it's not legitimate you can approach to consumer court. 

For further assistance contact me on

 

Prashant Nayak
Advocate, Mumbai
24239 Answers
51 Consultations

4.4 on 5.0

 

if the hospital is a government run hospital then you can prefer a writ petition in High Court against overcharging and for not charging as per the govt. circular 

Yusuf Rampurawala
Advocate, Mumbai
6435 Answers
54 Consultations

5.0 on 5.0

There is no such notification and settlement made on the basis of the terms and conditions of the policy you have so first read the terms and conditions, if something adverse then challenge the same for deficiency in service against both the insurance company as well as hospital.

Koshal Kumar Vatsa
Advocate, Gurgaon
2283 Answers
3 Consultations

5.0 on 5.0

From examining all the facts of your query I want to say that-
These cases are very common in various Courts of India and Supreme Court of India. I can understand your concern in this regard. This is a serious issue nowadays. Many people call me from various places of India for this purpose. There are already many cases against Hdfc Ergo General Insurance Co Ltd in various consumer forums, High Courts and Supreme Court.
These uncertainties affect patients who have bought, or want to buy, health insurance to protect themselves from high-priced Covid-19 treatment. Besides regulation by government agencies like the IRDAI, customers have approached various courts to seek regulation of Covid-19 treatment prices at private hospitals and complaining about non-reimbursement of claims by insurance companies.
In August 2020, a Supreme Court bench looking into a petition on this matter chastised insurance companies: “When there's a pandemic, insurance companies can't keep their hands off.” “It is submitted that if such inflated billing by the private hospitals can become a cause of concern for the insurance industry, what will be the plight of a common man who neither has a fat wallet nor an insurance cover to reimburse, in case, he requires hospitalisation in a private hospital (sic),” says this ongoing petition at the Supreme Court. The petition pointed out that due to the lockdown-led economic downturn, many patients do not have ready cash to pay hospitals and thus need insurance companies to come through on cashless claims. It asked the court to direct insurance companies to settle all claims at government capped prices. The case is still ongoing in the Supreme Court.

Now, to take legal action you can file a complaint with Insurance Regulatory and Development Authority (IRDA) set up as autonomous body under the IRDA Act, 1999. It protects the interests of policyholders, to regulate, promote and ensure orderly growth of the insurance industry and for matters connected therewith or incidental thereto. You can file the complaint online.
You can also send a legal notice through good Advocate to build pressure on them. A legal notice is, therefore, a formal communication to a person or an entity, informing the other party of your intention to undertake legal proceedings against them. This notice, when sent, conveys your intention before the legal proceedings and thus, makes the party aware of your grievance. Many times, a legal notice served will bring the other party on heels, and the problem can get resolved out of court too, with fruitful discussions on both sides. And, if the other party is still not heeding to the grievance, one can always start the court proceedings after a particular interval, as stated by the law. Although a legal notice can serve as a purpose of negotiations between the parties and save time, effort and money that are usually spent in court cases. Compensation for mental and physical agony can demanded by sending this legal notice.

You may contact my secretary to connect with me for clarification.

Gopal Verma,
Advocate on Record & Amicus Curiae,
Supreme Court of India

Shri Gopal Verma
Advocate, New Delhi
308 Answers
5 Consultations

4.0 on 5.0

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