A company, while renewing a health insurance policy, cannot change the terms and conditions. If changes are made to the terms and conditions, it has to be done with the consent of the consumer, ruled the District Consumer Redressal Forum (DCRF).
The forum was hearing a complaint filed by Sunita Marathe against an insurance company, through Consumer Welfare Association. In her complaint, Marathe said she had taken a health insurance policy in 2007-2008, which was renewed in 2008-2009. However, she was diagnosed with breast cancer in 2008 and was operated at Nanavati hospital. She incurred an expenditure of Rs56,893 for the operation and treatment. When she claimed the amount, the company sanctioned the entire claim.
She had to undergo further medical treatment after the operation, which cost her Rs75,934. Marathe alleged that when she approached the company, only half of the amount was sanctioned. Marathe then filed a complaint with the DCRF on June 2010.
The company claimed that the terms and condition of the policy had clear provisions that in case of any radiation therapy or medical advice thereof only 50% amount will be paid. "According to the policy, we have rightfully sanctioned 50% of the claim and there is no deficiency of services," the company stated before the forum.
The forum, however, held the insurance company guilty of deficiency of services, the forum asked it to reimburse the amount with interest. It has also directed the company to pay Rs5,000 towards the cost of the complaint.