CR142 Disputed health insurance claim – materials used in surgical procedure not covered

See too: CR, Dispute of Facts,

CR142

Disputed health insurance claim – materials used in surgical procedure not covered

Background

The contract is a heath insurance policy, which provides a hospitalisation benefit and also covers the cost of medical or surgical procedures defined as such in the “Medical Association of South Africa’s Guide to Fees for Medical Services”. The procedure the policyholder underwent was the insertion of two stents. The major expense involved was the cost of the stents themselves. The insurer ruled that the stents were “materials” which were not covered by the policy.

AsseDiscussionssment

As the insertion of the stents was the entire reason for the surgical procedures the complainant took the view that it was quite irrational not to cover the costs of the stents. Having examined the “MASA 2004 Guide to Billing for Medical Services” it is apparent that only medical procedures featured in the guide and there is no reference to materials. The implants, the stents themselves, would have been provided by the hospital and the hospital would have charged separately for these. Consequently one can argue that the insurer acted within the terms of the contract in denying liability for the cost of the stents. However, it was the view of the Ombudsman that the exclusion of costs relating to devices implanted or deployed intra-operatively is quite unusual and the Ombudsman decided that, on equity grounds, the insurer should make some adjustment to take account of contemporary methodology.

Result

The insurer agreed to settle approximately two thirds of the costs on an ex gratia basis.

DM
April 2006

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