Insurer to pay P’kula woman more than ₹1 lakh for surgery, harassment

The district consumer disputes redressal forum, Chandigarh, has directed an insurance company to refund a claim of over ₹82,000 to a city woman, who underwent eye

The district consumer disputes redressal forum, Chandigarh, has directed an insurance company to refund a claim of over ₹82,000 to a city woman, who underwent eye surgery, and to pay her ₹15,000 in compensation for causing harassment.

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Asha Sachdeva, a resident of Sector 20, Panchkula, had filed a complaint against Oriental Insurance Company, Sector 17-A, Chandigarh. She stated that she bought a mediclaim policy, covering herself and her husband Chiman Lal Sachdeva, valid from October 13, 2016 to October 12, 2017.

In April, 2017, Sachdeva suddenly lost her vision and was diagnosed with total retinal detachment in the left eye by the Grewal Eye Institute, Sector 9, Chandigarh. She underwent surgery (pars plana vitrectomy) in an emergency on April 20, 2017.

When Sachdeva submitted her claim to the insurance company, with a total bill of ₹82,390, they rejected the claim on the ground of pre-existing disease. She served them a legal notice, but to no success, following which she filed a complaint with the forum.

The insurance firm contested the claim and pleading that the claim was repudiated in July 2017 on the grounds of pre-existing disease which is excluded for four years, and also as per a clause, under which the treatment for the disease is not payable for a specified period. The firm also denied all other allegations of deficiency in service or unfair trade practice on its part.

The forum observed that it was legitimately proved that the claim was repudiated on imaginary grounds without there being any rationale. “Hence the repudiation of genuine claim of the complainant by the opposite party without any rhyme and reason amounts to deficiency in service and unfair trade practice on its part, which further aggravated the pain and harassment of the complainant,” the forum observed.

Partly allowing the claim, the forum directed the insurance company to pay the claim amount of ₹82,390 to the complainant, along with interest at 9% pa from the date of repudiation till realisation.

The forum also directed it to pay to ₹15,000 as compensation for harassment and ₹7,000 as litigation cost to the complainant.