Insurance firm told to reimburse Rs 73K medical expenses, relief

Legal Correspondent

Ludhiana, August 2
District Consumer Disputes Redressal Commission president Sanjeev Batra and its member Monika Bhagat have directed United India Insurance Company to reimburse expenses incurred by an aggrieved consumer during hospitalisation. The firm has been told to pay Rs 73,200 to the patient. Besides, it was also told to pay Rs 20,000 compensation to the consumer.
The insurance company had rejected his medical claim, saying that it was not payable as patient’s treatment could be managed without hospitalisation.
The orders came on a complaint moved by Kulwinder Singh, a resident of Goslan village in Samrala. The commission specifically held that the denial of medical claim was not justified.
The complainant had submitted before the commission that he took a cashless Individual Health Insurance policy from United India Insurance through Policy Bazaar, effective from June 27, 2018, to June 26, 2019.
He suffered severe stomach pain on May 31, 2019, and sought medical treatment. Despite fulfilling all procedural requirements, his requests for cashless treatment were repeatedly denied by the insurance company.
He initially consulted Dr Preet Kamal Sharma, who recommended hospital admission due to the severity of his condition. Later, he was admitted to the Dayanand Medical College and Hospital, Ludhiana, where he was treated for acute pancreatitis. The request for cashless treatment was denied on the grounds that his condition could be managed without hospitalisation in an OPD, which was contradicted by doctors who treated him.
Despite submitting all necessary documents for reimbursement after his discharge on June 9, 2019, the claim was rejected without sufficient explanation. He alleged that the insurance company’s actions caused significant financial strain, forcing him to borrow Rs 73,200 from relatives to cover his medical expenses.
Refuting the allegations, the lawyer of the insurance firm argued that the claim was not payable as the treatment could be managed without hospitalisation. However, the commission found the insurance company’s reasoning unconvincing. They noted that the complainant’s admission was medically necessary, as confirmed by multiple certificates from doctors.
The commission ruled that the denial of the claim constituted deficiency in service and ordered United India Insurance to reimburse consumer medical expenses with 8 per cent annual interest from the date of admission till full payment. Additionally, the company was directed to pay Rs 20,000 as compensation for the mental agony and inconvenience caused. The consumer, Kulwinder, expressed relief at the decision, hoping it would serve as a precedent for improved service from insurance providers.