Finding an insurance company in the wrong for only partly covering the complainant’s medical bill, the District Consumer Disputes Redressal Commission directed the firm to settle the medical claim of ₹40,000 and pay a compensation of ₹7,000.
The complainant, Manjit Singh Chahal of Khanna, had undergone surgery at Columbia Asia Hospital, Patiala, in 2018. The operation had cost ₹1,28,546, of which the insurer paid ₹85,918 and the complainant had to pay around ₹42,000 from his pocket. The complainant approached the insurer on numerous occasions but to no avail.
Accusing the insurance of deficient services, the complainant requested the forum to settle his claim and pay him a compensation of ₹1,50,000.
Seeking dismissal of the complaint, the counsel of the insurance company contended that the complaint was premature, and that Chahal did not approach the Park Mediclaim Insurance for the settlement of his claim nor the complainant deposit the receipt for the payment made.
“The complainant should have lodged a complaint with the firm if the claim had been repudiated. On receipt of a request for cashless payment on September 10, 2018, permission to pay the hospital up to ₹40,000 was granted through a mail dated September 12, 2018. After the final bill of ₹1,28,546 was received, ₹85,918 was sanctioned. However, due to an inadvertent error, the total amount sanctioned ₹1,25,918 could not be communicated to the hospital, due to which it charged the difference from the complainant,” said the insurance company.
{{/usCountry}}“The complainant should have lodged a complaint with the firm if the claim had been repudiated. On receipt of a request for cashless payment on September 10, 2018, permission to pay the hospital up to ₹40,000 was granted through a mail dated September 12, 2018. After the final bill of ₹1,28,546 was received, ₹85,918 was sanctioned. However, due to an inadvertent error, the total amount sanctioned ₹1,25,918 could not be communicated to the hospital, due to which it charged the difference from the complainant,” said the insurance company.
{{/usCountry}}The commission, in its order, said, “The complainant had to pay ₹40,000 from his own pocket as the total sanctioned amount of ₹1,25,918 could not be intimated to the hospital, which clearly amounts to deficiency of service on the part of the insurance company.”
“The argument that the complainant should have lodged a regular claim does not appear to be tenable considering the fact that it stands admitted on the part of the insurer that they intended to pay the final bill to the tune of ₹1,25,918 which was required to be paid directly to the hospital,” he said.