Insurance firm fined, told to pay Rs 4L medical claim to Nayagaon resident

Ramkrishan Upadhyay

Chandigarh, April 25

The District Consumer Disputes Redressal Commission, Chandigarh, has penalised an insurance company for wrongly denying medical claim to consumers.

The commission has directed the insurance company to not only pay a claim of Rs 4,20,597 to the complainants along with interest @ 9% per annum, but also pay Rs 7,500 compensation on account of mental tension and harassment Rs 7,000 litigation costs.

In the complaint, Rupnarayan Yadav, a resident of Nayagaon, said he purchased a health insurance policy from Cigna TTK Health Insurance Company Ltd covering himself, his wife and both children after paying a premium of Rs 11,533 on February 28, 2018.

He said his son Govind Yadav (complainant number 2) was admitted to the PGI, Chandigarh, for bone marrow transplant from August 4, 2018 to September 15, 2018. He incurred a sum of Rs 4,20,597 on his son’s treatment.

He submitted the documents for release of medical reimbursement on October 10, 2018. However, the opposite party (insurance company) rejected the claim vide letter dated January 7, 2019 on the ground that genetic disorder and stem cell implantation/surgery, harvesting, storage or any kind of treatment using stem cell were excluded under the policy.

He said as per the medical report/opinions, treatment undergone by his son was not a genetic disease. Therefore, the repudiation of the claim was illegal and unjustified. PGI’s medical consultant, who conducted the bone marrow transplant, gave a certificate on January 29, 2019 and February 26, 2019 stating that the disease was not a genetic, but acquired in nature.

The insurance company said the report was analysed by house doctors. After going through medical documents, it was found that as per Clause (Permanent Exclusion) Sub-Clause 1, genetic disorder and stem cell implantation/surgery, harvesting, storage or any kind of treatment using stem cell were not covered under the policy. They submitted that the claim of the complainants was rightly repudiated as per the terms and conditions of the insurance policy.

After hearing the arguments, the commission observed that the report of the Department of Haematology, PGI, Chandigarh, was placed on record, which revealed that the treatment for which Rupnarayan’s son was admitted was not genetic in nature. A test conducted on March 20, 2018 also revealed that the treatment was not genetic in nature.

The commission said it was very clear from the certificate that the complainant number 2 was not suffering from genetic disorder, but acquired in nature. It was evident from this certificate that the OP had wrongly and illegally repudiated the claim of the complainants, which amounts to deficiency in service. In view of the above discussion, the OP is directed to pay a mediclaim of Rs 4,20,597 to the complainants along with interest @ 9% per annum from the date of its repudiation i.e. January 07, 2019 till its actual realisation. It also directed to pay Rs 7,500 compensation for mental tension and harassment and Rs 7,000 as litigation expenses to the complainant.