Insurance firm told to pay Rs11.85L to officer for repudiating mediclaim

Jalandhar, March 22

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The District Consumer Redressal Commission has directed a Mumbai-based insurance firm to pay Rs11,85,250 to a city resident for repudiating his medical claim.

Sanjay Kainth (44), a resident of Shastri Nagar, used to work as a development officer in Pucca Bagh-located Life Insurance Corporation (LIC) office since 1996. LIC purchased a group medical health insurance policy for all its employees known as ‘Tailor made Group Medi Claim Cashless Policy’ from Mumbai-based New India Assurance company, vide which all employees of the LIC were medically insured. Another insurance firm India Health Insurance acted as a mediator.

Being the permanent employee of LIC, Kainth became the beneficiary and was insured under the said medical policy of the company to the tune of Rs10 lakh. The insurance amount was enhanced to Rs20,00,00 in 2018 as part of the annual renewal policy.

Unfortunately, on December 16, 2017, during the insured period, Kainth felt severe pain in his abdomen and was immediately taken to a private hospital, where he remained admitted for one week. Since no major improvement was seen in his health, he was referred to DMC Hospital in Ludhiana. A bill to the tune of Rs65,075 was generated by the private hospital. Since the said hospital was not an empanelled hospital of the insurance firm for cashless facility, Kainth paid the entire bill of Rs65,075 with the impression that the same would be reimbursed by the insurance company.

At DMC, he remained hospitalised for about 19 days from December 23 to January 11, 2018, for his treatment. At the time of discharge, a bill of Rs2,52,037 was generated by the DMC Hospital, but as it was an empanelled hospital of the insurance company, cashless facility was available to the complainant. As such, no amount was to be payable by him towards his medical treatment expenses, as the same was to be paid by the company directly to the DMC Ludhiana.

Within eight days of his discharge, he again suffered severe pancreatic disorder and remained hospitalised for about 49 days. During his treatment, Kainth requested the hospital to give him cashless treatment, but the hospital authorities told him that the company had refused to provide him the cashless facility. He was also told that even the earlier bill of Rs2,52,037 was not paid by the company. Hence, he had to pay the entire treatment expenses.

The complainant immediately spoke to the company regarding the same, who told him that they had not denied the claim of the complainant and they had only denied cashless facility to him, however, he could get reimbursement of his claim. He was compelled to pay the entire hospital treatment charges including medicines and lab expenses. He paid the entire refund of Rs9,95,737 to the DMC.

After taking discharge, he applied for reimbursement of his claims, but he was denied the same and was made to run from pillar to post for the settlement of his claim, but to no avail. Meanwhile, he again underwent an operation and paid Rs1,14,313 at the DMCH.

Following the repudiation of his claim by the insurance company, he filed a complaint against the company on January 21, 2019, and sought reimbursement of the bill and Rs50,000 as the cost of litigation. — TNS