The West Bengal Clinical Establishment Regulatory Commission has initiated an inquiry into allegations of fraudulent billing practices at four private hospitals following a complaint from a private insurance company. The insurer alleged unnecessary hospital admissions, prolonged hospital stays, manipulation of medical records, and inflated billing, prompting the Commission to examine the matter as a broader issue affecting healthcare billing practices.
Insurance Company Flags Alleged Billing Irregularities
According to the Commission, the written complaint names four private hospitals—one in Kolkata, one in Durgapur, and two in Siliguri. The insurer submitted four sample cases alleging fraudulent transactions, and all the hospitals have since filed written responses to the allegations.
The Commission stated that although the hospitals responded only to the specific bills cited in the complaint, the matter would be examined as a wider issue concerning billing practices in private healthcare institutions.
Allegations Include Unnecessary Admissions and Inflated Bills
The insurance company alleged that patients were admitted despite there being no medical necessity, while some hospital stays were extended beyond the clinically required duration.
It also alleged that single surgical procedures were divided into multiple bills to increase reimbursement amounts and that medical records were altered to justify the billing pattern submitted to the insurer.
The Commission is examining these allegations as part of its inquiry.
Commission Orders Refund in Separate Insurance Dispute
In a related matter, the Commission directed a private hospital in Kolkata to refund ₹58,000 to a patient who had paid the amount after the insurer declined to settle a portion of the hospital bill.
The hospital argued that the insurer had wrongly rejected the claim. However, the Commission held that any dispute regarding the rejected amount should have been resolved directly with the insurance company rather than recovering the amount from the insured patient.
Commission Questions Recovery from Patient
The Commission also heard another complaint involving a patient whose surgery cost exceeded more than twice the original estimate. Although the patient had health insurance coverage of ₹5 lakh, the hospital billed ₹4.21 lakh, of which the insurer approved only ₹2.64 lakh.
Questioning the hospital’s approach, the Commission observed that charges disallowed by the insurer should not have been recovered from the patient. The hospital maintained that the insurer had incorrectly rejected part of the claim.
The Commission is continuing its examination of the complaints and the hospitals’ responses.
Important Highlights
- The West Bengal Clinical Establishment Regulatory Commission is probing four private hospitals over alleged insurance billing irregularities.
- The insurer alleged unnecessary admissions, prolonged hospitalisation, inflated billing, and manipulation of medical records.
- All four hospitals have submitted written replies to the Commission.
- In a separate case, the Commission directed a Kolkata hospital to refund ₹58,000 recovered from a patient after an insurance claim was partially rejected.
- The Commission has questioned hospitals for recovering disputed insurance amounts directly from insured patients instead of pursuing the matter with the insurer.
