Insurance firms penalised for refusing claim to elderly

Ishrat S Banwait

Tribune News Service

Chandigarh, April 24

Two insurance companies have been penalised for refusing a claim saying that their permission was not sought by the complainant before getting a surgery done. The district consumer forum has thus directed The Oriental Insurance Company Limited and Medi Assist Insurance TPA Private Limited to pay Rs 1.40 lakh to the complainant.

The complainant in the case is a senior citizen, who is a former Oriental Bank chief manager. Devki Nandan Vaid, a Panchkula resident, in his complaint said along with his wife Minakshi Vaid, he had a medical insurance cover under Oriental Bank Mediclaim Policy. The policy was valid from June 12, 2014, to June 11, 2015, and the sum insured was Rs 5 lakh. The premium of Rs 6,830 was paid and earlier to this, in the preceding years 2013-14 and 2012-13, similar policies were taken. The third party administrator (TPA) of the said policy was Medi Assist India.

The complainant’s wife was diagnosed for cataract of the right eye on February 13, 2015, and underwent a femto cataract surgery on February 16, 2015, at Mirchia’s Laser Eye Centre. However, the cashless facility could not be availed of. The reimbursement claim of Rs 1.15 lakh was submitted to the opposite parties. After much effort, a sum of Rs 26,267 was reimbursed.

In its reply, the insurance companies said before undertaking the operation in the hospital, their permission was not taken. Therefore, the total amount of the reimbursement claim was not allowed and the ‘reasonable amount’ of Rs 26,267 was reimbursed.

As per the forum’s judgement, the operation was done from the own empanelled hospital of the opposite parties. “Thus, it does not lie in the mouth of the opposite parties to disallow the remaining part of the claim on the ground of unreasonableness,” it says.

The order further reads: “The complainant and his wife are senior citizens at the wrong side of 70 and their claim ought to have been given top priority by the opposite parties who had charged the premium.”

The forum thus directed the companies to pay Rs 88,800 i.e. difference of total claim along with Rs 30,000 as compensation for deficiency in service, undue harassment and mental agony. An additional Rs 20,000 are also to be paid as costs of litigation.

The order

The order said: “The complainant and his wife are senior citizens at the wrong side of 70 and their claim ought to have been given top priority by the opposite parties who had charged the premium.” The forum directed the companies to pay Rs 88,800 i.e. difference of total claim along with Rs 30,000 as compensation for deficiency in service, undue harassment and mental agony. An additional Rs 20,000 are also to be paid as costs of litigation.