Insurance firm penalised for denying claim

Ramkrishan Upadhyay

Tribune News Service

Chandigarh, March 11

The District Consumer Disputes Redressal Commission, Chandigarh, has penalised an insurance company for denying the claim of medical treatment to a consumer. Finding the excuse given by the company as unreasonable, the commission has directed the company to pay Rs 3,33,748 spent on the medical treatment of a consumer. It also directed the company to pay Rs 15,000 as compensation for causing mental agony and harassment and Rs 10,000 as cost of litigation.

Amarjit Singh, a resident of Mohali, approached the commission after he was denied the claim of treatment of his wife by the company.

The order

Finding the excuse given by the company as unreasonable, the District Consumer Disputes Redressal Commission, Chandigarh, has directed the insurance company to pay Rs 3,33,748 spent on the medical treatment of a consumer. It also directed the firm to pay Rs 15,000 as compensation for causing mental agony and harassment and Rs 10,000 as cost of litigation.

He said he had a family health insurance plan from The New India Assurance Company since the past many years. On being allured by Star Health and Allied Insurance Company Limited for better coverage and service, he agreed to port his family health policy with it and paid the premium of Rs 24,072 vide a cheque dated April 5, 2018, to the company.

The policy was valid from April 15, 2018, to April 14, 2019. It provided coverage to his wife, Sukhwinder Kaur also. On September 24, 2018, his wife Sukhwinder Kaur had a medical emergency and was admitted to Fortis Hospital, Mohali, where she was implanted with stents and remained in Hospital for about two days. The total cost of the medical procedure raised by the hospital was Rs 3, 33,748. When the claim was submitted, the insurance company denied the payment on December 1, 2018. Not only this, even the company sent another letter dated December 3, 2018, for the cancellation of the policy from January 12, 2019.

On the other hand, the insurance company contested the consumer’s complaint. The company claimed that the complainant had concealed the pre-existing disease of his wife Sukhwinder Kaur as she was hospitalised from May 31, 2007, to June 1, 2007, and was treated for retroperitoneal fibrosis and underwent ureterolysis with biopsy with DJ stent and was on tablet tamoxifen from 2013.

After hearing the arguments, the commission noted that the arguments of the company could not be accepted. It said as per records, the pre-existing disease was cured in 2013 and, therefore, it cannot be said she had concealed the disease so as to invoke this exclusion clause to deprive the complainant of the claim Thus, by repudiating the genuine claim of the complainant, the company is proved to have indulged in deficiency in service and unfair trade practice. In view of this, the company is directed to pay the claim of Rs 3, 33,748 to the complainant along with interest at the rate of 8 per cent per annum from the date of repudiation (December 1, 2018, till realisation. The commission has also directed to pay an amount of Rs 15,000 to the complainant as compensation for causing mental agony and harassment to him and Rs 10,000 as cost of litigation.