IMA STAND ON LIFE SAVING MACHINES, DEVICES, EQUIPMENTS
Life saving machines, devices such as pacemaker, CPAP, BIPAP, Orthopedic implants, intra cardiac valve replacements, vascular stents, relevant laboratory diagnostic tests, X-Ray and such similar implants, machines are often prescribed by registered medical practitioners to their patients.
As per IMA all such life saving equipments are and should be fully covered in insurance policies / mediclaim /PSU reimbursement etc.
IMA policy has also been validated by the following judgments:
1. In case titled as “The New India Assurance Co. Ltd. & Anr. Versus Mrs. Sonali Sareen & Anr.” during the course of treatment in Sir Ganga Ram Hospital, the patient was recommended to purchase the CPAP/Bipap machine. Since the purchase of the machine was recommended by the treating doctor complainant purchased the same for a sum of Rs. 70,000/- and thereafter lodged the claim under the cashless insurance policy. The Ld. District Fourm had held that purchase of machine was the part of the treatment and without this machine the patient could not have been treated. Thus, the denial of the payment of this price of the machine tentamounts to deficiency of service on the part of the insurance company. The said order and judgment passed by Ld. District Forum had been duly accepted by the Hon’ble State Consumer Disputes Redressal Commission vide order dated 09.12.2014.
2. Further, in the matter titled as “New India Assurance Co. Ltd. versus Ganashyamadas A. Thakur,” vide order and judgment dated 07.02.2014, Hon’ble National Consumer Disputes Redressal Commission had held that:
“The fact that Respondent/Complainant wife had taken treatment as an in-patient at M/s Bhagwan Mahaveer Jain Hospital for Severe Obstructive Sleep Apnea is not in dispute. It is further an admitted fact that on discharge she was advised CPAP usage at night as a continuing part of the treatment to regulate her breathing and ensure that there was adequate inflow of oxygen since the CPAP had to be used alongwith 1-2 litre oxygen/minute. Keeping in view this important fact, we find force in the conclusion reached by the Fora below that like the pacemaker, which is used to control abnormal heart rhythms, the CPAP device though not an implant is a continuous positive airway pressure to keep the airways open and thus like the pacemaker is not only an integral part of treatment but necessary for patient survival. No doubt Clause 2.4 of the policy does not mention CPAP but it is obviously not a comprehensive list because it talks of various devices like pacemaker. As stated above, since the CPAP device like the pacemaker is important for the patient treatment and survival, it may not be reasonable to exclude it. Apart from this, in the exclusion clause, on which the Petitioner/OP had relied before the Fora below, it is stated that the Insurance Company will not be liable to make any payment in respect of the equipments, such as braces, non-durable implants, eyeglasses, contact lenses etc. These may be important but are not life-saving equipments unlike the CPAP. So far as the hospitalization of Respondent/Complainant daughter is concerned, we also agree with the conclusion reached by the Fora below and directing the Petitioner/OP for reimbursement of the same.”
Accordingly, all members of IMA are advised to educate their patients who has been prescribed any such life saving equipment.
All members are further requested to help their patients in this regard so that they can get their treatment reimbursed.
Dr S S Agarwal Dr K K Aggarwal
National President, IMA Padma Shri & Dr B C Roy National Awardee, Honorary Secretary General, IMA