E-Paper
Ludhiana | Insurance company directed to reimburse ₹3.6L medical claim
The District Consumer Disputes Redressal Commission has directed United India Insurance Company Ltd to reimburse a medical claim of ₹3, 65,064, along with ₹7,000 compensation, to a Ludhiana-based complainant after his claim was rejected by the insurance company
The District Consumer Disputes Redressal Commission has directed United India Insurance Company Ltd to reimburse a medical claim of ₹3, 65,064, along with ₹7,000 compensation, to a Ludhiana-based complainant after his claim was rejected by the insurance company.
Narinder Kumar Batra of New Kidwai Nagar had submitted a complaint against the aforesaid insurance company through its senior divisional manager (referred as OP1) and against M/s Vipul Medcop Insurance TPA Private Ltd, B-416, Ansal Chamber I, Bikaji Cama Palace, New Delhi.
The complaint
Batra had submitted that he obtained an individual health policy from the said insurance company and there was no gap in the period of the insurance policies and in all the policies, the date of inception was mentioned as May 28, 2008.
It was further alleged that on July 26, 2017, the complainant had chest pain following which he went to Hero DMC Heart Institute, Ludhiana, and was diagnosed as a patient of CAD-acute coronary syndrome.
The complainant remained admitted in the hospital from July 29, 2017 to August 05, 2017 and underwent a coronary artery bypass grafting, incurring expenses of ₹3,65,064 on his hospitalisation.
The complainant sent due intimation to the opposite parties at the time of his admission in the hospital.
However, his insurance claim was repudiated by the senior divisional manager after a period of more than one year on the ground that the complainant was a known case of CAD and the disease was pre-existing in nature.
The complainant further claimed that the repudiation of the claim was illegal and arbitrary as the terms and conditions of the policy were not explained at any point of time. Moreover, no proposal form was filled at the time of issuing the policy and he had no history of the said illness and was admitted with a complaint of chest pain only for the last three days prior to his admission.
Submitting his complaint, Batra sought his claim of ₹3,65,064, along with interest @12% per annum and compensation of ₹2,00,000.
The complaint, however, was resisted by the senior divisional manager. In a written statement, the manager had pleaded that after the completion of formalities and obtaining the documents, the opposition party found that the claim was not payable and was repudiated as per the terms and conditions of the policy.
“The complainant was found to be a known case of CAD which was pre-existing in nature. The policy was only in its third year of operation from November 14, 2014 onwards. The previous policy had expired on May 12, 2014 that was not renewed within the grace period of 30 days and there was a gap of 93 days. As per the policy, all the pre-existing diseases are covered only after 48 months of continued coverage. Therefore, the claim has been rightly repudiated,” the counsel for the senior divisional manager stated.
The order
Meanwhile, the commission observed that in the discharge summary, there was no mention that the complainant was suffering from coronary artery disease since November 14, 2014 or any time prior to it.
“No doubt, in the discharge summary it is mentioned that the complainant had a history of CAD but there is no mention of the duration of disease nor any record has been proved by the insurance firm to show that the complainant was suffering from the disease on November 14, 2014 or any time prior to it or had taken treatment for the same. Therefore, the firm were not justified in repudiating the claim,” read the order.
The commission pronounced that in the given circumstances, it would be just and proper if the opposite party was directed to consider and reimburse the claim in question, strictly in accordance with the terms and conditions of the policy, along with a composite cost of ₹7,000.
