Insurance firm, TPA told to pay Rs 4.79L for refusing claim

Chandigarh, October 25

The District Consumer Disputes Redressal Forum has directed an insurance company and a third-party administrator (TPA) to refund Rs 4.79 lakh to a local resident for rejecting claim and to pay Rs 25,000 for deficiency in service.

Kamal Brij Mohan Arora, a resident of Mani Majra, Chandigarh, filed a complaint against Bharti AXA General Insurance Company Ltd, Chandigarh, and Paramount Health Service and Insurance TPA Pvt Ltd, New Delhi.

The complainant, a director of Kawal Construction Pvt Ltd, had purchased a group health insurance policy from Bharti AXA General Insurance for his employees for the period from October 28, 2016 to October 27, 2017, on payment of premium of Rs 90,000.

He was also covered under the group insurance policy and was diagnosed with chronic plaque psoriasis in May-June 2017. A Bombay-based skin specialist had advised him to get admitted in the hospital for cashless hospitalisation and Nishant of Paramount Health Services and Insurance TPA Pvt Ltd acknowledged that claim was payable in pre and post OPD and no such objection was raised for the indoor treatment.

He was admitted at a hospital in Mumbai for a day for the treatment and the hospital had raised bill of Rs 4,79,740 and it was submitted to Paramount Health Services.

However, despite many reminders, the amount was not reimbursed to Arora, hence he moved the forum and prayed for settlement of the claim for Rs 4,79,740 along with interest, compensation of Rs one lakh and Rs 50,000 towards litigation expenses.

Bharti AXA General Insurance Company Ltd contested that complainant was the director and not an employee of Kawal Construction Pvt Ltd and therefore, not a consumer and was not covered under the policy.

It was further mentioned that the injection administered for chronic plaque psoriasis could have been done as outdoor patient. The outdoor reimbursement was not admissible to the complainant or his employees. “The complainant with a view to couch the claim within the medical reimbursement cover admitted himself in the Lilavati Hospital and then asked for the claim. On these lines, the cause is sought to be defended,” they pleaded.

The other party did not revert, hence it was proceeded ex-parte. After hearing the arguments, the forum observed, “We have also perused the bills raised of the alleged amount. The figure has also not been disputed by the OPs. Thus, the OPs were wrong in repudiating the claim of the complainant which amounts to deficiency in service and unfair trade practice on their part.”

Thus, the Forum directed the opposite parties to reimburse the amount of Rs 4,79,740 to Arora along with interest at 9 per cent per annum from the date of repudiation that is November 13, 2017 till realisation.

The Forum also directed them to pay Rs 15,000 as compensation for causing mental agony and harassment to him and to pay Rs 10,000 as litigation cost. — TNS