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HindustanTimes Fri,24 Oct 2014

Insurance firm must clear patient’s claims 2 years after death

Charul Shah, Hindustan Times  Mumbai, June 16, 2012
First Published: 02:19 IST(16/6/2012) | Last Updated: 02:20 IST(16/6/2012)

Two years after his death, a consumer forum ordered an insurance company to pay health insurance to the wife of a cancer patient; for a complaint registered by the patient with the forum four years ago.

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After the patient, Harris Valapil, passed away in 2010, his wife was brought on record in the case.

The district consumer forum, south Mumbai, has asked the insurance company to pay with interest for the medication Valapil took as part of the treatment.

Valapil was diagnosed with prostate cancer in 2003. The doctor advised radiotherapy and Zoladex, a hormonal treatment, which he was given every month.

Valapil in his complaint said the doctor increased the dose of Zoladex  from 3.6 mg per month to 10.08 mg quarterly from November 2004.   The complainant submitted the claims to the company, which were regularly settled till November 2005.

Thereafter, the insurance company rejected Valapil’s claims, citing a clause. He approached the Insurance Ombudsman, but did not receive help. 

As the insurance company refused to comply, Valapil moved the consumer forum in January 2008. He alleged that since the insurance company had allowed all his prior claims for the same treatment till November 2005, rejecting the claim after that date amounted to deficiency in service. He also alleged the company had adopted unfair trade practices.

The company, however, submitted that the complainant’s previous claims had been settled as per the policy conditions, that is, expenses as part of treatment of chemotherapy, radiotherapy etc. However, the administration of the Zoladex injection was not a part of chemotherapy and was  a follow-up treatment without hospitalisation.

The forum rejected the insurance company’s contention after observing that the treatment of chemotherapy and Zoladex was continued and claims were paid for by the insurance company till November 2005 — 60 days after his hospitalisation ended.

The forum observed that the insurance company had rejected Valapil’s claim on the wrong grounds.

It has asked the company and a third party agency to pay the insurance claim of Rs43,052 with interest at 9% per annum from June 2006 till the time payment date. They have also been asked to pay Rs5,000 towards the cost of the complaint and Rs10,000 for mental harassment.


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