The following is a case study published in OFS Annual report:
Saloma was admitted on a day-care basis on 27/05/2021 for “irritable bowel syndrome”. She submitted follow-up bills dated 24/8/2021 to the insurer for reimbursement under the 90 days post-hospitalisation treatment benefit, i.e., 28/5/2021-25/8/2021.
However, the insurer paid only consultation charges, and the medication charges were excluded as they exceeded the 90-day post hospitalisation period from the discharge date.
Post-Hospitalisation Treatment Benefits states as follows: –
“C. DESCRIPTION OF BENEFITS
6. POST-HOSPITALISATION TREATMENT BENEFIT
Reimbursement of the Reasonable and Customary Charges incurred in Medically Necessary follow-up treatment by the same attending Physician within the maximum of ninety (90) days and amount as set forth in the Schedule of Benefits immediately following discharge from the Hospital for a non-surgical disability.
This shall include medicines prescribed during the follow-up treatment but shall not exceed the supply needed for the maximum ninety (90) days as set forth in the Schedule of Benefits.
On 22/7/2021, Saloma’s entire family was infected with COVID-19 and required quarantine. Hence, her follow-up on 24/7/2021 had to be postponed, and the admitting doctor rescheduled it to 24/08/2021. Saloma’s delayed treatment is reasonable, considering her entire family was infected with COVID-19 and under quarantine, with her father’s condition being critical. Further, the follow-up treatment could not be rescheduled earlier due to the tight schedule of the doctor.
Additionally, we find that a literal interpretation of the policy provision gives the impression that the prescribed medication for post-hospitalisation treatment is for a maximum of 90 days post-discharge. The table of benefits states, “90 days after hospital discharge”. It did not state within 90 days following discharge from the hospital. Hence, Saloma’s claim is still within the policy coverage.
Based on the above factors, the Ombudsman allowed Saloma’s claim in full.