Insurance firm penalised, asked to pay Rs 44,000 claim

Tribune News Service

Amritsar, September 19

The District Consumer Disputes Redressal Forum has directed an insurance company to pay Rs 44,025 to a local woman along with Rs 2,000 as litigation expenses, whose claim was repudiated.

Earlier, Saroj Sharma along with her husband Ramesh Kumar, both residents of Vijay Nagar, filed a complaint against Max Bupa Health Insurance stating that they had ported their insurance policy from National Insurance to the opposite party after persuasion by its agents.

The complainants stated that they had paid a premium of Rs 12,118 for Rs three lakh, the sum assured.

Saroj complained that during the validity of the insurance she was hospitalised and operated for fibroadenosia, a common disorder of the breast resulting from hormonal imbalance. She stated that she spent Rs 44,025 on her treatment, but the insurance company refused to give the claim.

The opposite party stated that as per documents provided by the complainants, it was found that Saroj had undergone breast surgery in 2012 also. According to the pre-existing disease clause, they were not entitled to pay the claim, said the firm.

The forum observed that as the complainants were regular holders of the policy since 2012 from where they had shifted to the opposite party under portability scheme, the clause of pre-existing disease does not hold good for repudiation of the claim.

The forum said the opposite party had rejected the claim without any rhyme and reason.

It further stated that as the company had not apprised the complainants about terms and conditions of the policy, it cannot apply them in this case.