Forum penalises insurance firms for refusing claims

Ishrat S Banwait

Advertisement

Tribune News Service

Chandigarh, November 25

The District Consumer Forum continued its stern stance against medical insurance firms denying claims to consumers. The forum in the recent order has fined two such firms who have now been told to pay nearly Rs 2.50 lakh each for refusing two such claims.

In one such case, Davinder Kumar, a resident of Karnal, approached the forum against Syndicate Bank, Karnal, United India Insurance and Med Care Health Insurance Company. Kumar had purchased a mediclaim policy via the bank worth Rs 5 lakh in October 2013.

In December, when the complainant was at his sister’s house in Chandigarh, he suddenly felt uneasiness and was taken to Fortis Hospital, Mohali. Eco and other tests were done by doctors at Fortis Hospital, Mohali. After getting reports, the doctor advised him to immediately go for Aortic Valve Replacement (AVR). It is submitted that the complainant approached both companies, but was denied the claim on the ground of pre-existing nature of illness.

However, it was not pre-existent and even the doctor, who treated Kumar, issued a certificate regarding the same. The complainant spent Rs 2.44 lakh at the hospital and once again asked for reimbursement, which was denied.

The companies kept demanding various documents, which were submitted, but still refused the claim. The forum observed that the documents are to be sought all at once and not in ‘piecemeal’.

The forum thus asked the respondents to reimburse Rs 2.47 lakh to Kumar, along with Rs 15,000 as compensation for harassment suffered and litigation expenses to the tune of Rs 7,000.

In another such case, Mohali resident Pritpal Singh had purchased HDFC Life Health Assure Plan worth Rs 3 lakh in July, 2015, which covered his family as well. The company itself got medical tests done and found them in perfect medical condition. However, in April 2016, Pritpal’s mother suffered chest pain and was taken to a hospital. The doctors diagnosed her with Acute AWMI loaded with anti-patelets, statin and was advised for CART plus revascularisation. Thereafter, the mother of the complainant was admitted to Ivy Hospital and was discharged after angioplasty and payment of the bill of Rs 2.20 lakh.

Singh lodged a claim with HDFC for reimbursement of the medical expenses incurred by him, but the same was rejected by it on the ground of incorrect information and non-disclosure of fact that she was diabetic and a patient of hypertension.

However, the forum found the firm deficient in service and asked it to reimburse the cost of medical treatment to the tune of Rs 2.20 lakh to the complainant and pay an amount of Rs 15,000 as compensation for causing him mental and physical harassment, along with litigation expenses of Rs 7,000.