Pay relief, health insurance firm told
Ishrat S Banwait
Tribune News Service
Chandigarh, February 22
The District Consumer Disputes Redressal Forum has directed an insurance firm to pay over Rs 3 lakh to a city resident for refusing a health insurance claim. The wife and son of the complainant were insured in the policy but after his wife got treatment for her ailment in a hospital, the firm had refused to refund the amount, stating that the medical condition was a pre-existing one. However, the plea did not hold up in the court.
A Sector 29 resident, RS Bisht had purchased New India Floater Mediclaim Policy for his wife and son, along with himself, after paying Rs 9,090 as premium. Their medical examination was also conducted and the insurance was to be valid from July 22, 2014, to July 21, 2015. The firms involved were The New India Assurance Company Limited, Sector 34, and Raksha TPA Private Limited, Sector 44.
As per the complaint, the wife of the complainant, Babita Bisht, complained of stomach pain in September 2014 and was admitted to a private hospital in Mohali on September 12, 2014, and discharged on January 27, 2015, which was intimated to the firms. Despite the treatment, Babita expired on May 13, 2015. Bisht lodged the claim with the firms for an amount of Rs 2.86 lakh on January 1, 2016. However, his claim was refused, saying that it was a pre-existing ailment.
In their reply, the firms said the policy inception was one-and-a-half month old and no previous treatment records were provided by the complainant, despite reminders.
They said the ailment was known as a case of CA stomach and it was of chronic nature. The policy in question was running in its first year and the claim was not payable as per terms and conditions of the policy and thus, the claim was rightly rejected.
The forum observed that Babita Bisht had no past history of any disease. The particular disease suffered by her came to the knowledge of the complainant for the first time. There is no question of any intentional concealment of any fact. It thus, directed both firms to pay an amount of Rs 2.86 lakh to the complainant, along with a compensatory cost of Rs 10,000 and a litigation cost of Rs 5,000.
The case
As per the complaint, the wife of the complainant, Babita Bisht, complained of stomach pain in September 2014 and was admitted to a private hospital in Mohali on September 12, 2014, and discharged on January 27, 2015, which was intimated to the firms. Despite the treatment, Babita expired on May 13, 2015. Bisht lodged the claim with the firms for an amount of Rs 2.86 lakh on January 1, 2016. However, his claim was refused, saying that it was a pre-existing ailment. the forum observed that Babita had no past history of any disease. The disease suffered by her came to the knowledge of the complainant for the first time. There is no question of any intentional concealment of any fact. It thus, directed both firms to pay Rs 2.86 lakh to the complainant, along with a compensatory cost of Rs 10,000 and a litigation cost of Rs 5,000.
