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Denying med claim costs insurance firm dear
The district consumer disputes redressal commission has fined an insurance firm for denying the medical claim of a Samrala resident.
The district consumer disputes redressal commission has fined an insurance firm for denying the medical claim of a Samrala resident.
The firm, United India Insurance Company, has been directed to pay ₹79,606 of hospital bills with interest at 8% per annum and a composite fee of ₹20,000 to Kulwinder Singh, 43, of Goslan village.
The complainant approached the commission on June 28, 2021, claiming that he had a cashless treatment insurance plan with the firm, which he bought through online platform PolicyBazar.
He alleged that the firm did not provide cashless treatment and also rejected his reimbursement claims.
Singh said that the policy was valid from June 27, 2018, to June 26, 2019, and insured him for ₹1 lakh at a premium of ₹2,006.
He added that he suffered a severe stomachache on May 31, 2019, and went to a local physician who prescribed some medicine. After his condition deteriorated on the same day, he was admitted to the Dayanand Medical College and Hospital (DMCH). The doctors provided treatment for acute pancreatic disease, loose motion and fever. He applied for cashless treatment on June 1, 2019, but the insurance company rejected the claim. He reapplied for the cashless treatment on June 2, 2019, by attaching the opinion of the doctors, who suggested that the patient cannot be managed on an OPD basis and requires a hospital stay.
Two employees of the insurance company visited the hospital on the same day and took a record from the hospital. Later, they rejected cashless treatment stating that the treatment can be managed on an OPD basis.
The complainant added that he was discharged from the hospital on June 9, 2019. As he was in a financial crisis, he borrowed money from his siblings to pay the bills. He moved an application for reimbursement of the bills on June 22, 2019. In reply, the insurance company asked him to send original bills and other documents. He sent the requisite documents on September 2, 2019. In December, the company rejected his claim file without specifying a reason.
The insurance company submitted to the forum that the treatment could be managed on an OPD basis and the claim was not payable as there was no need for hospitalisation.
The forum observed that according to the treating doctor and specialist’s opinion, the patient’s admission was urgently required. “It may also be noticed from the discharge summary that the complainant was suffering from stomach pain for the 10 days associated with vomiting and fever. It was not a pre-appointed health check-up. The ailment of the patient was diagnosed and treated when he was in the hospital. Had he not been admitted to the hospital, there could have been a possibility of more serious repercussions for his health. No prudent person will admit himself or herself in the hospital conditions where there is a risk of contracting infection more than at home,” the forum observed.
