Insurance firm penalised for denying full medical claim

The State Consumer Disputes Redressal Commission, Chandigarh, has directed an insurance company to pay compensation of Rs 20,000 to a city resident for denying full claim for medical treatment.

Passing the order on an appeal filed by city resident Saroj Kumar Sharma, the commission also told the firm to pay balance claim amount of Rs 53,079 to the complainant, along with interest @ 9% per annum.

Saroj Kumar has challenged the order of the District Consumer Disputes Redressal Commission dated October 7, 2024.

He said he approached the district commission after the insurance company refused to pay the entire amount of the treatment.

The complainant said while allowing his complaint the district commission had directed the company to pay balance claim amount of Rs 53,079 to him along with interest @6% per annum. He added that the district commission has not awarded compensation for mental agony and harassment suffered by him. The complainant further submitted that even the interest given 6 per cent is also on the lower side

Saroj Kumar said he had purchased a Mediclaim Policy from the insurance company by paying a premium of Rs 12,308. In November 2022, his daughter-in-law faced some health problem and visited to a private hospital in Mohali’s Phase 6. After conducting some tests and on the advice of doctor he admitted his daughter-in-law to the hospital on November 1, 2022 and she was discharged on November 5 after treatment.

An amount of Rs 79,625 was incurred on the treatment of the woman. The information was given to the insurance party by the hospital to provide the cashless facility.

The hospital provided all the required documents to the company and only an amount of Rs 25,000 was approved. The balance bill amount of Rs 53,079 was paid by the complainant from his own pocket.

He said although the district commission partly allowed the complaint and directed the insurance company to pay Rs 53,079 incurred by him on the treatment of his daughter-in-law, yet, it erred in not awarding compensation for mental agony and harassment he had to suffer. He submitted that even the interest @6% per annum awarded by the district commission on the amount of Rs 53,079 is on the lower side and needs to be enhanced.

After hearing of the arguments the State Commission has directed the insurance company to pay the balance claim amount along with interest @9% per annum.

The commission also directed to pay Rs 15,000 as cost of litigation to the complainant.