Proportionate Deduction: A decision in favour of the Insured

Dispute between              Haresh Shah v/s Reliance General

Award/Complaint no      IO/BNG/A/HI/0255/2019-20

Cause of dispute              Short Settlement (proportionate deductions)

Amount of claim              158161

Relief sought                    64043

Decision in favour of       Insured

Date of Award/Order       7/2/20

Location                            Bangalore

                                         

Brief facts  

The total claim amount was Rs. 158161 but Rs. 64043 was deducted as  proportionate to room rent. The insurer submitted that the Insured Person was eligible for single private room but he opted for ultra special room.

Ombudsman's ruling   

During the course of the hearing, the insurer submitted a re-verified  claim calculation as follows

                                               

                                         

List of deductions:

Sr no		Bill Type	Claimed amount	Eligible amount	Disallowed	Remarks
	1	Room and nursing charges	58000	49000	9000	Deducted as per tariff
2		Oxygen charges	23540	23540
3		Professional fees	15400	13013	2387	Proportionate deductions
4		Consultation charges	850	718	132	Proportionate deductions
5		Bedside procedures	2190	1851	339	Proportionate deductions
6		Investigation charges	37586	31760	5826	Proportionate deductions
7		Medicine & consumable charges	17371	15570	1801	Non medical expenses-310;thermometer-891;bed bath towels-540;bactorub-60
8		Medicine & consumable charges	574		574	Non medical payables
9		Miscellaneous charges	1700		1700	Admission charges not payable
10		Documentation charges	950		950	Not payable
		Total	158161	135542	22709

 

As cashless amount of Rs.81967 had already been paid, Balance amount of Rs.54320 was payable to the insured.           

Remarks   

Actual room eligibility was Rs.9800. The Insured Person stayed in a room where charges where 11600. Applying the formula: ((Actual - Eligible rent)/Actual rent) we get 15.5%. Hence charges are deducted by 15.5%. Note that expenses like thermometer, bath towels etc. are not payable.