Insurance firm told to pay Rs 7.90 lakh to complainant

Ishrat S Banwait

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Tribune News Service

Chandigarh, December 29

The Consumer Forum has directed Apollo Munich Health Insurance Company to pay Rs 7.90 lakh to a consumer for refusing their health claim. The firm had refused the claim saying that the treatment availed by the consumer was ‘experimental’ and not approved. However, the forum struck down its argument and decided in favour of the consumer.

Ambala resident Harish Singhal and his son Dhruv Singhal had approached the forum after the former’s claim was refused. Harish (46) had bought Optima Restore Insurance Policy, a cashless health insurance for Rs 10 lakh, under which his wife, Poonam was also insured.

Poonam was diagnosed with Metastatic Adenocarcinoma Gallbladder (poorly differentiated) with liver mets, Stage IV, for which they took her to a private hospital in New Delhi on July 6, 2016. She visited the hospital and was admitted multiple times for treatment in the next four months.

Singhals filed for cashless claim with the company which was rejected on November 25, 2016. The company claimed that the treatment was “unproven and experimental only and was not approved by the FDA and such treatments aren’t covered/payable”.

As a result, Singhals had to pay the entire amount of Rs 7.55 lakh themselves. Singhals once again filed for reimbursement, but in the, meanwhile, Poonam expired on January 28, 2017. Despite repeated reminders, the company did not reimburse the medical bills as per their application to the forum.

The firm in its defence said experimental treatments were not covered under cashless facility. However, they did not receive any reimbursement application from Singhals. The forum found that no reimbursement application was filed by the consumer. However, it was also placed on record that the treating doctor and the hospital had sent a mail to the company informing them that the treatment is neither experimental nor unproven.

However, the company still did not provide the claim and was found deficient in service by the forum. It was, thus, ordered to reimburse Rs 7.55 lakh along with compensation of Rs 25,000 for causing mental and physical harassment and litigation cost of Rs 10,000 to the complainants.