One of my clients recently had a case which I am explaining below and if you are stuck in such similar situation, here is what to do.

Note: Due to attorney-client privilege, I cannot disclose complete case details or identify the actual parties involved. However, I am sharing the essential facts and legal approach so that if you find yourself in a similar situation, you can understand the available solutions and legal remedies.

Mr. X took his mother to ABC Heart Hospital in City A for an angiography procedure. Initially, the hospital staff was very cooperative and friendly. The insurance company approved coverage for Rs. 14,300 for the procedure. However, after the test was completed successfully with no cardiac issues found, the hospital demanded an additional Rs. 15,000 from Mr. X, claiming additional charges not covered by insurance. When Mr. X questioned this, he discovered the hospital had submitted inflated bills to the insurance company while demanding extra payment from the family. The hospital had claimed Rs. 25,000 from insurance but received only the approved Rs. 14,300, then tried to recover the difference from the patient despite the original treatment estimate being much lower.

Advice in Such Cases

Consult with Lawyer: The very basic and important step to start is talk to Lawyer / advocate. You should not hesitate in paying his consultation fee i.e. might be in range of Rs. 10,000 to 50,000 depends case to case. He is helping you in this situation to come out. He is expert in the domain and can help you explain the procedure which you might have never explored. A good lawyer can get the issues resolved much faster than you think.

• Collect all hospital bills, insurance documents, and correspondence as evidence
• File complaints with insurance company’s grievance cell and hospital administration
• Report the matter to local medical council and consumer forum for dual action

Applicable Sections of Law

Under Bharatiya Nyaya Sanhita (BNS), Section 318 covers cheating and dishonestly inducing delivery of property. Section 319 addresses cheating by personation, applicable when hospitals misrepresent treatment costs. Section 61 defines criminal conspiracy when hospital staff collectively plan fraudulent billing. Under Bharatiya Nagarik Suraksha Sanhita (BNSS), Section 173 governs complaint filing procedures and Section 394 covers investigation of fraud cases by police authorities.

If You Are the Complainant

• File FIR at local police station under fraud and cheating sections
• Submit written complaint to insurance company with all supporting documents
• Approach consumer court for compensation and punitive damages
• Report to State Medical Council for professional misconduct proceedings
• Maintain detailed records of all communications and evidence collected

If You Are the Victim

• Do not pay disputed amounts until proper investigation is completed
• Request itemized bills and treatment records from hospital administration
• Contact insurance company immediately to report fraudulent claims
• Seek second opinion from another medical facility for treatment validation
• Document all conversations with hospital staff and maintain evidence files

How the Police Behave in Such Cases

Police typically treat hospital fraud cases seriously due to public interest involved. They usually conduct preliminary inquiry to verify documents and may summon hospital administrators. Investigation includes examining hospital records, insurance communications, and patient treatment files. Police coordinate with insurance company investigators and medical authorities for technical aspects of the case.

FAQs People Normally Have

Can hospitals charge extra beyond insurance coverage? Only pre-disclosed amounts with proper documentation and patient consent.

What if insurance company refuses to pay hospital claims? Hospital cannot demand payment from patient for their billing disputes with insurers.

Is overcharging insurance companies a criminal offense? Yes, it constitutes fraud under BNS and can lead to criminal prosecution.

How to verify if hospital bills are genuine? Cross-check with insurance pre-authorization and market rates for similar treatments.

What Evidence Is Required?

• Original hospital bills and treatment receipts with detailed breakdown
• Insurance policy documents and pre-authorization letters
• Hospital admission records and discharge summary
• Communication records between hospital and insurance company
• Witness statements from other patients or hospital staff
• Medical reports and test results supporting actual treatment given
• Bank statements showing payments made to hospital

How Long Will the Investigation Take?

Police investigation typically takes 60-90 days depending on case complexity. Consumer court proceedings may extend 6-12 months. Insurance company internal investigation usually completes within 30-45 days. Medical council inquiry can take 3-6 months for professional misconduct cases. Overall resolution may require 8-18 months across all forums.

Advocate Sudhir Rao, Supreme Court of India