Ludhiana | Insurance company directed to reimburse ₹2 lakh medical claim

Mohit Sharma of Ludhiana had submitted a complaint against the branch manager of opposite party (OP), Reliance General Insurance Company Ltd, Ludhiana, alleging deficiency in service for its failure to reimburse a medical claim of ₹2 lakh

For its failure to reimburse a medical claim of ₹2 lakh to a patient, District Consumer Disputes Redressal Commission on Sunday directed Reliance General Insurance Company Ltd to release the claim and pay ₹7,000 compensation to the complainant.

“The claim was not payable as the Ludhiana complainant was a known case of diabetes mellitus since 2011 and he was taking regular treatment for the said disease but this fact was not disclosed by the complainant in the proposal form at the time of policy inception”, averred the counsel for the insurance company. (HT FILE)

Mohit Sharma of Ludhiana had submitted a complaint against the branch manager of opposite party (OP), Reliance General Insurance Company Ltd, Ludhiana, alleging deficiency in service.

Sharma bought a medical policy from the OP in August 2015, which was renewed from time to time. The wife and minor son of the complainant were also covered under the said policy.

On December 12, 2019, the complainant was admitted to SPS Hospital, Ludhiana, due to a major heart attack.

The complainant remained admitted till December 14, 2019.

Since there was no cashless facility, the complainant spent an amount of about ₹2, 00,000 on his treatment.

After getting discharged from the hospital, the complainant applied for the reimbursement of the claim and submitted all the necessary documents with the said insurance company. Mohit said his claim was rejected by the OP and the policy was also cancelled on the ground that the former had not disclosed in the proposal form that he was suffering from diabetes.

The complainant asked the OP to provide him the proposal form and other documents, but the insurance company refused to do so, alleged Mohit.

Hence, the complainant sought reimbursement of the total bill of ₹2.02 lakh along with the compensation of ₹5 lakh.

However, refuting the allegations, the insurance company pleaded that the complaint was false and frivolous.

“The claim was not payable as the complainant was a known case of diabetes mellitus since 2011 and he was taking regular treatment for the said disease but this fact was not disclosed by the complainant in the proposal form at the time of policy inception”, averred the counsel for the insurance company.

Meanwhile, the Commission in its order observed, “It is a settled proposition of law that diabetes mellitus and hypertension are common diseases and it is not necessary that every person suffering from hypertension and diabetes mellitus would also suffer heart attack. Even otherwise, in this case the factum of non-disclosure of pre-existing disease of diabetes mellitus has not been established by the opposite party. Under these circumstances and considering the fact that the proposal form has not been placed on record by the OP, it has to be held that the repudiation of the claim by the OP is not justifiable and the same is liable to be set aside”.

Commission further directed the OP to consider and reimburse the claim in respect of hospitalisation of the complainant from December 12, 2019 to December 14, 2019, strictly, as per terms and conditions of the policy, and also to pay a composite of ₹7,000 to the complainant.