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Insurer directed to settle Mohali resident’s mediclaim of ₹2.83 lakh
Woman had a travel insurance policy when she was admitted to a UK hospital for epigastric pain; but insurer rejected her claim, stating the treatment was taken for a pre-existing disease
The District Consumer Disputes Redressal Commission, Chandigarh, has directed an insurance company to settle a Mohali resident’s rejected medical claim of ₹2.83 lakh.
The complainant, Jaspreet Kaur, had submitted that she had bought travel insurance in June 2017 through United India Insurance, which has its regional offices in Chennai and Chandigarh, before travelling to the UK.
Lasting from June 21 to December 17, 2017, the policy covered medical expenses, evacuation and repatriation to the extent of $50,000 besides other heads.
Kaur said she visited the UK in perfect health, but she got an unprecedented epigastric pain for which she was hospitalised at Forth Valley Royal Hospital, Larbert, UK, for a few days in July 2017.
The details were shared with the insurance company, but she got no reply, which led her to believe that they had paid the medical expenses.
However, in September 2019, she was detained by the Border Force at Edinburgh, Scotland, UK, for non-payment of bills and her husband had to pay ₹2.83 lakh to the hospital.
On questioning the insurer, she got to know that the claim was rejected on the grounds that treatment was taken for a pre-existing disease. Hence, alleging deficiency in service and unfair trade practice, Kaur moved the consumer commission.
In its response, the insurer submitted that the woman had been suffering from ulcerative colitis and asthma for the past 10 years, and pre-existing disease and related complications were not covered under the policy.
However, the commission observed that after a certain age, people often experienced occasional ailments every now and then.
“A number of diseases may exist simultaneously in the body with no direct relationship or connection with one another. In the instant case, the medical claim pertains to the epigastric pain and the ground of repudiation is the opinion of the doctor that the patient has a history of ‘ulcerative colitis and asthma’. However, these have no direct nexus/relation with epigastric pain,” the commission said.
Moreover, the insurance company had failed to produce on record any concrete and reliable documentary evidence to show that ulcerative colitis and asthma might have caused epigastric pain or have nexus with each other, it held.
Justifying the claim, the commission directed the insurance company to settle the claim without any delay and also directed it to pay ₹15,000 as compensation for harassment and litigation expenses.
“The act and conduct of the company in repudiating the genuine claim of the complainant amounts to deficiency in service,” it said.
