Ahmedabad: An insurance company cannot deduct money from a Mediclaim reimbursement on the ground that treatment was taken at a non-network hospital without establishing that the policy allows such a deduction, Ahmedabad District Consumer Disputes Redressal Commission has ruled.The commission directed National Insurance Company Ltd to pay Rs 5,500 to a policyholder after determining that the deduction from his cataract surgery claim was illegal and arbitrary. It also ordered the insurer to pay interest at 8% per annum from July 24, 2024, until realisation, along with Rs 2,000 towards compensation and litigation costs.The complainant, Keshubhai Prajapati, a resident of Satellite, who had a health cover, underwent left-eye cataract surgery at a hospital in Ahmedabad in March 2024. He incurred expenses of Rs 56,770, but the insurer deducted a certain amount under different heads, including Rs 5,500 towards co-payment for treatment at a non-network hospital.A non-network hospital is a medical facility that does not have a formal tie-up, contract, or pre-negotiated tariff agreement with the health insurance provider or its third-party administrator.Prajapati sued the insurer, contending that the insurer cannot compel the consumer to get treatment in a particular hospital. He alleged deficiency in service.The insurer maintained that the claim had been settled in accordance with the policy conditions and denied any deficiency in service.The commission, however, noted that the insurance company had failed to produce a copy of the policy terms and conditions. It also found that the insurer had not specified the clause under which the Rs 5,500 deduction had been made.
