Insurance company told to settle resident’s dispute

The Insurance Ombudsman for Punjab, Haryana, Himachal Pradesh, J&K and Chandigarh has directed Oriental Insurance Company Limited to pay Rs 5,134 to a city resident, Rakesh Satija, after deductions from his wife’s hospitalisation claim were found partly unjustified. The order, passed by Ombudsman Alka Jha, came following mediation under Rule 16 of the Insurance Ombudsman Rules, 2017.

Satija had filed a complaint under the Insurance Ombudsman Rules, 2017, alleging wrongful deduction of Rs 7,255 from his wife’s hospitalisation claim. His wife was admitted to the Dayanand Medical College and Hospital, Ludhiana, on May 9, 2024, for treatment of acute gastroenteritis.

Against a total bill of Rs 30,911, the insurer authorised a cashless treatment of Rs 22,745, deducting charges for vitamins, dietician consultation, patient kit and consumables.

During the hearing held on August 27, 2025, Satija argued that the deductions were unjustified since tests and charges were prescribed by the treating doctor at an empanelled hospital. The insurer maintained that the deductions were made in accordance with policy terms, excluding non-payable consumables and unrelated investigations.

The ombudsman observed that the insurer’s contention regarding “irrelevant investigations” did not hold ground as the medical tests were prescribed by the doctor.

In the course of mediation, the insurer agreed to settle the claim by paying Rs 5,134 to the complainant, after deducting Rs 2,121 for dietician charges and consumables. Satija accepted the settlement. The Ombudsman directed the insurer to comply with the recommendation within 30 days, warning that failure to do so would attract a penalty of Rs 5,000 per day under the Master Circular on Protection of Policyholders’ Interests, issued on September 5, 2024.