Consumer panel pulls up insurance firm, orders payment in 2006 case
The commission was hearing an appeal filed by a doctor after a complaint was filed over medical expenses. The complainant, Jaswantiben Kothari, died while the case was pending. The commission directed the insurance firm to clear the claim.
The State Consumer Disputes Redressal Commission came down heavily on insurance companies for dragging cases and not clearing insurance claims since 2007. It has requested Insurance Regulatory and Development Authority (IRDA) to develop a mechanism to check the abuse of process of law by insurance companies.
The commission was hearing an appeal filed by a doctor after a complaint was filed over medical expenses. The complainant, Jaswantiben Kothari, died while the case was pending. The commission directed the insurance firm to clear the claim.
Kothari underwent a knee replacement surgery in Bombay Hospital in August 2006. After the operation, Kothari approached the insurance company to claim her medical expenses of ₹95,095. The insurance company sanctioned only ₹43,287 for surgery. It rejected the claim of ₹50,000 for use of computer-aided surgery, body exhaust suits and jigs, which was separately charged by the doctor. Kothari approached the District Consumer Disputes Redressal Forum against the insurance company, hospital and doctor. The forum asked all parties to jointly pay for her medical expenses. The doctor, however, approached the commission.
During the hearing of the doctor’s appeal, the insurance company contested the claim and claimed that they are not liable for the separate bill. The complainant’s family argued that prior to operation, the company had assured them payment up to ₹1.5 lakh for the treatment. The firm claimed the bill was inflated.
The commission said the case is an abuse of process of law available to common consumers and the insurance firm and its third party agent (TPA) are guilty of deficiency in service. The commission exonerated doctor and hospital for payment. The insurance firm and TPA have been asked to pay 12% interest from 2007 within 30 days and ₹50,000 compensation to the family.