It should be noted that PPN rates are offered towards cashless medical claim made by those insured by government health insurance companies
In two separate cases, the consumer forum in Ahmedabad as ruled that an insurance company cannot deduct an amount from the total claim put forth by an insured on the basis that the said claim was higher than what was agreed with the Preferred Provider Network (PPN) hospital.
It should be noted that PPN rates are offered towards cashless medical claim made by those insured by government health insurance companies.
The hospitals in the PPN network offer specialised rates (pre-decided between the hospital and insurance company and often less than the actual rates) to customers of such insurance companies for specified illness and procedures.
In the first case, the court asked the United India Insurance Company to pay one Vrushali Deshpande her entire claim for a cataract operation. She had Rs 3 lakh insurance but the insurance company deducted Rs 18000 from her total claim stating that it was higher than the PPN rate agreed with the hospital for the said procedure.
The forum ordered that she be paid the Rs18000 with 8 per cent interest and Rs 4000 by way of expense.
In another case, 72 year old Harshvardhan Gandhi was paid just Rs 1.08 lakh of the Rs 3.36 lakh claim he had made for surgery following prostate cancer. Gandhi, a retired SBI employee had a Rs 5 lakh insurance policy with Oriental Insurance company.
In this case too the company said they had paid the agreed cost of the said procedure with the PPN and that they were not liable to pay the rest.
The forum ruled that Gandhi be paid the rest of Rs 2.26 lakh with 8 per cent interest.
Mukesh Parikh president of Consumer Protection and Action Committee who represented the insured in both the cases argued that the lack of payment amounted to deficiency in service and harassment.
The forum while ruling in favour of the insured in both the cases said that the PPN agreement is between the hospital and the insurance company.
It said the insured is not part of this agreement and hence cannot be subject to the agreement as nowhere in the two cases have the insured agreed to same. Hence it ruled that the insurance company will have to pay the entire cost of the claim as it was well within the insured limit.
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