E-Paper
Rejecting Himachal man’s mediclaim costs Fortis, insurance firm dear
His claim was rejected on the grounds that he suffered from diabetes mellitus and coronary artery disease before taking the policy. But a certificate from the hospital clarified that he was not suffering from any diabetic disease.
The District Consumer Disputes Redressal Forum has directed an insurance company and Fortis Hospital, Mohali, to pay around ₹70,000 to a Himachal Pradesh resident for rejecting his medical claim.
Complainant Dalip Kumar, a resident of Solan, Himachal Pradesh stated that he had bought an insurance plan from Cigna TTK Health Insurance Company Limited, Mumbai through its office in Chandigarh after payment of the premium.
The policy was valid from June 2, 2017 to June 1, 2018. Kumar alleged that on June 3, 2017, he felt a pain on the left side of chest, following which he was admitted in Fortis Hospital. He was discharged the next day on clearance of a bill of ₹34,819.
He said that his claim was rejected on the grounds that he suffered from diabetes mellitus and coronary artery disease (CAD ), which were pre-existing, however, the medical report of Fortis was wrong. Later, he got a certificate from the hospital clarifying that he was not suffering from any diabetic disease.
Following this, Kumar moved consumer forum demanding ₹₹34,819 and a compensation of ₹2 lakh for mental and physical harassment, ₹2 lakh for unfair trade practice and ₹25,000 as litigation cost.
COUNTER-CLAIM
Meanwhile, the insurance company contested that Kumar had suffered from the disease prior to the policy and the same was concealed by him before purchasing the policy. As such his case fell in exclusion clause and therefore, the claim was repudiated.
The Fortis Hospital claimed that the allegations made in the consumer complaint were directed against the insurance company and did not concern them. The hospital authorities stated that the complainant had himself informed them about the disease.
The forum observed that the Fortis Hospital has taken “an inconsistent, contradictory and paradoxical stand that they were told so by the complainant at the time of admission, while their own record shows, it was their own diagnosis.” The complainant had furnished the affidavit that he had not disclosed such disease to Fortis and rightly so.
Allowing the complaint, the forum directed the insurance company to pay ₹34,819 to Kumar at 9% interest per annum from the date of repudiation till realization.
Fortis Hospital was also directed to pay ₹20,000 to Kumar as compensation for causing mental agony and harassment and ₹15,000 as litigation cost.
