District Consumer Disputes Redressal Commission penalised an insurance company for not reimbursing a claim of ₹1.36 lakh to the complainant citing delay in filing the claim by the former.
Nazar Singh,62, of Gobind Nagar, submitted his complainant against Oriental Insurance Co Ltd, New Delhi, through its manager(OP1), Oriental Insurance Co Ltd, Miller Ganj, Ludhiana, manager (OP2), MD India Insurance TPA Private Limited, Maxpro Info, SAS Nagar, Punjab, director/Manager (OP3) and the director, Government of Punjab, department of health and family welfare (health branch), Chandigarh (OP4).
The complaint
Complainant Nazar Singh and his mother Ajaib Kaur were covered under the Punjab Government Employees and Pensioners Health Insurance Scheme (PGEPHIS).
During the currency of the policy, Kaur felt ill and was hospitalised with Guru Teg Bahadur Hospital, Ludhiana, from December 07, 2016 to December 21, 2016. She was again admitted in Shree Raghunath Hospital, Ferozepur, from December 24, 2016 to December 29, 2016. Ajaib Kaur, however died on December 29, 2016 in the aforesaid hospital.
Total amount of ₹1, 36,180 was spent on her treatment and medicine.
{{/usCountry}}Total amount of ₹1, 36,180 was spent on her treatment and medicine.
{{/usCountry}}Complainant lodged a claim with the OPs, but the same was repudiated by OP3, following which the complainant accused that the repudiation of the claims was illegal and arbitrary.
Singh submitting his complaint with the commission sought compensation of ₹40,000 along with the claim.
Since OP4 did not appear before the commission, he was proceeded against exparte.
The complaint was resisted by the other OPs.
The counsel for OP1 and OP2 said since the claim was submitted after 30 days from the date of discharge, the OP1 and OP2 were unable to entertain the same.
OP3 also prayed for dismissal of the complaint voicing the same contention that the beneficiary was only eligible for reimbursement, subject to submission of the claim to the TPA within 30 days from the date of discharge from the hospital.
The commission said it was not disputed that the mother of the complainant Ajaib Kaur was covered under the policy.
The commission observed, “However, in our considered view, merely on the ground of delay of 63 days in lodging the claim, the same cannot be allowed to be repudiated by invoking clause. In the instant case, the mother of the complainant did not survive and after the death of his mother, the complainant must have been busy in performing her post-death rites.”
Commission added that in the clause there is no mention that in the event of non-submission of the claim within 30 days from the date of discharge from the hospital, the claim would be rejected or repudiated.
The commission, thus, directed the OP1 and OP2 to reimburse the claim and also to pay ₹5,000 compensation.