Insurance firm delays medical claim, fined

Tribune News Service
Amritsar, April 21

The district consumer disputes redressal forum has directed an insurance company to pay Rs 10,000 as compensation and Rs 5,000 as litigation expenses for delaying the medical claim of a local resident.

Complainant Darshan Talwar of Gali Sunyareyan, a retired government official, had filed a complaint against Oriental Insurance, stating that he had obtained a mediclaim policy for him and his wife under the Punjab Government Employees and Pensioners Health Insurance scheme.

He stated that his wife remained admitted to a private hospital and underwent treatment for ‘upper GI bleeding, severe sepsis with acute respiration failure’. The complainant intimated the insurer immediately at the time of admission.

His wife died on August 10, 2016. He had incurred a total expenditure of Rs 1,13,060 on the treatment. He alleged that the opposite party failed to reimburse the medical claim even after repeated requests after which he filed complaint November 15, 2016.

The insurance company replied that the claim was approved as per terms and conditions of the policy and in accordance with approved schedule of rates for an amount of Rs 79,439 and the said amount was duly credited into the account of the complainant on February 23, 2017.

The forum observed that during the pendency of the present proceedings, the opposite party paid a sum of Rs 79,439 against total amount of Rs 1,13,060. The forum stated that no doubt the opposite party had settled the claim of the complainant as per PGEPHIS rates but the same was settled during the case proceedings.

The forum stated that the opposite party delayed the genuine claim of the complainant which it was bound to settle within 15 days from the date of lodging of the claim, so the opposite party is liable to pay compensation, stated the forum.

The case

Complainant Darshan Talwar of Gali Sunyareyan had filed a complaint against Oriental Insurance, stating that he had obtained a mediclaim policy for him and his wife under the Punjab Government Employees and Pensioners Health Insurance scheme. His wife died during treatment on August 10, 2016 and he incurred Rs 1,13,060 on her treatment. He filed his claim but didn't get desired reponse. He filed a case in November 2016 and the firm settled the claim in February 2017.