Insurance firm penalised for denying medical claim

Tribune News Service

Chandigarh, January 14

The consumer forum here has slapped a fine of Rs 17,500, including litigation fee, on Max Bupa Health Insurance Limited for not paying medical claim amount to a Zirakpur resident. The forum has also asked the insurance firm to pay the claim amount of over Rs 91,000 to the complainant.

The complainant, Czarina Jindal, said she took Heartbeat Health Insurance Policy for a sum assured of Rs 25 lakh by paying the requisite premium. During the period - January 9, 2015 to January 8, 2016 - of the policy, the complainant fell ill and was diagnosed with the problem of meningioma.

Doctors advised her to go for surgery and she was admitted to AIIMS on July 10, 2015, for operation. After the operation, she submitted all bills/documents to the insurance firm on October 20, 2015, for reimbursement of the medical claim of Rs 91,599.

However, the insurance company did nothing. During the interregnum, the policy also got renewed by the complainant by paying the premium of Rs 14,059. After sometime, it refunded the premium for the period 2016-17. On enquiry, the complainant was informed that her entire claim was rejected on the ground of Non-Disclosure Clause and PED Clause 4 (a) of the policy.

In its reply to the forum, the firm stated the complainant was a known case of intracranial meningioma since prior to policy inception and had underwent craniotomy for the same in the past, which was not disclosed by her at the time of taking the policy.

“...there was no hospitalisation or operation during the last seven years and the complainant was not taking any medicine for any type of disease. Furthermore, the opposite parties have miserably failed to prove that the complainant had fallen sick during the last seven years..,” said the forum headed by presiding member Surjeet Kaur and member Suresh Kumar Sardana.

Meanwhile, the forum also directed the company to renew the policy for year 2016-2017.