Insurance firm fined for rejecting medical claim

To pay Rs54,389 as insurance claim and Rs10K as compensation

Tribune News Service

The case

  • Hira Lal, a resident of Putlighar, had filed a complaint against ICICI Lombard General Insurance stating that he had purchased a medical insurance for his family. When his son was hospitalised, he spent Rs 54,389 on his treatment but the firm repudiated his claim. Despite his requests, his grievances were not addressed. Now, the firm has been asked to approve his claim.

Amritsar, November 17

The district consumer disputes redressal forum has directed an insurance company to pay Rs 54,389 as medical insurance claim and Rs 10,000 as compensation for arbitrarily rejecting the claim.

Hira Lal, a resident of Putlighar, had filed a complaint against ICICI Lombard General Insurance Company Ltd stating that he had purchased a medical insurance for his family from the opposite party. He stated that his son was hospitalised during the validity of the policy and he spent Rs 54,389 on medicines, tests and hospital expenses. The complainant alleged that he sent repeated emails to the insurer against the repudiation of the claim, but his grievances were not addressed.

The opposite party stated in its reply that it had appointed an official who investigated the case and came to the conclusion that the claim of the complainant was based on false facts and had recommended repudiation of the claim. The reply stated that the investigator had recorded the statement of the patient who admitted that he was not admitted to the hospital but had taken the OPD treatment.

The forum stated that the letter of repudiation couldn’t be accepted. No specific reason was given by the opposite party for rejecting the claim, it stated.

The forum further observed that it was shocking to see that in the said letter in the column of reason and remarks, the firm had simply typed a standard exclusion clause only and despite having received many emails from the complainant, it never disclosed the reason for the rejection of the insurance claim. The opposite party failed to prove its allegations to justify its impugned repudiation through some cogent evidence necessary to be produced during the present proceedings and as such these amount to bald statements, the forum stated.

It pointed out that no name and designation of the investigator or even his affidavit had been filed. It stated that the insurer had based its above repudiation decision solely on presumptions and hearsay evidences and the same were not admissible in judicial adjudicatory. It stated that when the hospitalisation of the complainant’s son was proved from the discharge card issued by the hospital, in that case a self incriminating statement of the complainant’s son cannot be made the sole basis for arbitrarily rejecting his genuine claim.

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