Ludhiana | Consumer forum directs insurance firm to reimburse mediclaim of ₹34 K
Ludhiana-based complainant alleged that his daughter Ishika tested positive for dengue on December 07, 2019 and was discharged on December 12, 2019 for which he lodged a claim for reimbursement of the hospital expenses of ₹34,880 from the insurance firm
Finding an insurance company in the wrong for not reimbursing a medical claim of ₹34,880 to a complainant, the District Consumer Disputes Redressal Commission directed the firm to reimburse the claim, along with a compensation of ₹5,000.
Sushil Goyal of Khanna, Ludhiana, submitted a complaint against The Oriental Insurance Company Limited, New Delhi. through its managing director (referred to as opposite party 1 or OP 1), The Oriental Insurance Company Limited, Ludhiana, through its branch manager (OP 2), M/s Raksha Health Insurance, Faridabad, through its Branch Head (OP 3) and M/s Raksha TPA, Ludhiana, through its branch manager (OP 4).
Sushil Goyal, in his complaint, stated that he purchased a medical health insurance policy from the opposite parties, which was valid from January 30, 2019 to January 29, 2020. Previously too , he had a policy that was valid from January 30, 2018.
The policy covered the complainant, his wife Vanita Goyal and two children Ishika Goyal and Divyanshu Goyal.
It was further alleged that his daughter Ishika tested positive for dengue on December 07, 2019 and was discharged on December 12, 2019 for which the complainant lodged a claim for reimbursement of the hospital expenses of ₹34,880.
After the receipt of the claim, OP 4 demanded certain documents, but the complainant had submitted those, along with the claim form.
Despite this, OP 1 and OP 2 in connivance with OP 3 and OP 4 repudiated the claim on September 18, 2020.
Resisting the complaint, in a joint written statement, the OPs pleaded that the complaint was time barred and the complainant did not apply for any cashless treatment for his daughter Ishika Goyal in respect of her treatment at Guru Amar Das Clinic and Physiotherapy Centre, Khanna.
“After getting discharged from the hospital, the complainant neither lodged any claim nor submitted any document with TPA or the insurance company within the prescribed time. After the receipt of the claim from the complainant, OP 3 scrutinised the documents and gathered information and found that some documents were not provided by the complainant and thus the claim was not considered,” contended the counsel for the opposite parties.
Further, appealing to dismiss the complaint, the opposite parties stated that during the investigation by OP 3, it was found that Guru Amar Das Clinic and Physiotherapy Centre, Khanna, was a nine-bed hospital and as per the policy condition, the treating hospital should have at least ten in-patient beds.
The commission, however, observed that in regard to the condition as to whether Guru Amar Das Clinic and Physiotherapy Centre, Khanna, was a ten-bed hospital or not, the OPs had relied upon the investigation report that mentioned that the investigator visited the hospital and verified the details and confirmed that it was only a nine-bed hospital.
“The investigation report was not signed by anybody. Contrary to this, the counsel for the complainant has relied upon and referred to a certificate where Punjab Pollution Control Board has referred to the hospital as ten bedded— the authorisation given to the hospital under Bio-Medical Waste Management Rules, 2016.”
Commission further added the hospitalisation of the patient for five days did not seem to be a case of overstay and therefore, the repudiation of the claim due to non-supply of the certificate of a doctor does not appear to be tenable.
“It would be just and proper if the OP 1 and OP 2 are directed to consider and reimburse the claim in respect of hospital expenses of patient Ishika Goyal, along with composite costs of ₹5,000,” pronounced the commission.