The district consumer disputes redressal forum, Chandigarh, directed an insurance company to pay Rs 20,000 as compensation to a resident of Zirakpur for deficiency in services and unfair trade practices.
Disposing of the complaint filed by Ghanshyam Lal Goyal, the forum directed United India Insurance company limited and Medsave Health Care (TPA) limited them to pay Rs 47,623, along with 9% interest from January 2012 (the date of reimbursement of his partial claim), till it was actually paid.
Apart from this, Goyal would also be paid Rs 10,000 as cost of litigation.
Goyal was dependent on his son, who works with a private company. In November 2011, he underwent a heart surgery. He claimed that he was eligible for cashless facility, but it was not paid and thus he had to pay the entire amount of the surgery. He alleged that a claim was filed with the insurance company but they paid only part of the amount spent on treatment.
In their reply, United India Insurance and Medsave Health Care claimed that the insurance policy was issued in name of a private company. Denying any deficiency, they claimed that the complainant is the father of an employee and as per the special exclusion of terms and conditions of the insurance policy, in case of parents' claim, 25% co-payment was to be borne by the employee for procedure/surgeon charges insured under the policy.
The forum presided over by Rajan Dewan on July 30 held, “The insurance company was, in fact, trying to deny the claim on frivolous grounds of his not being consumer and having accepted the assessed amount without protest. We feel the act of the insurance company in not assessing the entire claim even though when there was no shortcoming in his claim documents certainly amounts to deficiency in service.
We feel that the insurance company tried to even short charge the complainant…..This act of the insurance company certainly amounts to unfair trade practice on their part.”