E-Paper
Chandigarh: Insurer penalised for rejecting mishap victim’s mediclaim
Company denied mediclaim stating that dental charges related to implant were excluded from their policy
A Zirakpur woman, who had approached the District Consumer Disputes Redressal Commission, Chandigarh, over rejection of mediclaim by the insurer following an accident, has been awarded the complete claim, along with compensation for mental harassment.
The commission directed Religare Health Insurance Company Limited to pay the claim amount of ₹1,15,793 to the complainant with interest at 9% per annum from the date of filing the complaint. The company was also asked to pay ₹10,000 as compensation for causing mental agony and harassment, and ₹5,000 as cost of litigation.
Divya Bhola, the complainant, had alleged that she availed of a health insurance policy from Religare Health Insurance that was valid till January 2021.
In December 2019, she met with an accident and was taken to Alchemist, Panchkula. It was found that both her nasal bones were fractured and there were multiple fractures on her face, so dental correlation was advised.
The insurance company was intimated and cashless approval was sought. The company accordingly approved cashless medical reimbursement of ₹44,897. As per doctor’s advice, dental implantation was to be done after recovering from the internal injuries.
Divya submitted bills of ₹1,23,793 issued by the hospital and chemists to the insurer. But the company reimbursed only ₹8,000.
The insurance company stated that the hospitalisation claim was approved and given directly to the hospital as it was a cashless claim. Thereafter, the complainant also filed a post hospitalisation claim of ₹1,18,500, out of which ₹8,000 was approved for root canal therapy charges.
Stating that there was no deficiency on their part, the company replied that the dental charges related to implant were excluded as per the policy terms and conditions. As per clause, implants/cosmetic surgery are excluded from the policy.
The company, while admitting the factual matrix of the case, stated that the complaint was not maintainable against it, as no relief had been sought against it.
The court observed, “In our opinion, the clause is not applicable to the instant case as the implantation was done by the complainant due to injuries suffered in the accident only and cannot be termed as cosmetic surgery.”
“Moreover, the unilateral terms of policy cannot be imposed against the gullible consumers who pay huge premium amounts to the insurance company, but at the time of reimbursement the insurance company takes shelter of such unilateral clauses. Hence, there is merit in the case of the complainant and the same is liable to be allowed,” it added.
The commission, thus, directed the insurance company to pay the remaining claim amount, along with compensation for mental harassment, to the complainant.
