Insurance News: CERS helps Ahmedabad resident win insurance claim for hernia surgery

Consumer Education & Research Society’s (CERS) continuous efforts to protect interest of the consumers have once again produced desired result, since the Consumer Disputes Redressal Forum, Ahmedabad (City) in a recent order has accepted its plea objecting to unfair trade practice adopted by one of India’s leading firm, Oriental Insurance and ordered the insurer to settle the claim made by an Ahmedabad resident, which was dismissed earlier on the pretext of some conditions of the contract.

As per the case details, Pravinchandra Soni, a resident of the city, had purchased a healthcare insurance for him & his wife since 2004 and the policy was renewed every year thereafter. A few years down the line, Soni got operated for hernia at a private hospital on February 10, 2009 and claimed the entire cost of the surgery i.e. Rs. 24,010 under the policy. However, the insurance company – Oriental Insurance Company Ltd, a public sector undertaking, partially settled the claim and limited the amount to Rs. 9,300 only, saying that the insurance cover was given under the Universal Health Plan in 2004 and it was converted into Medicliam policy at a later stage. As per the conditions of the new plan, the treatment for hernia was excluded for the period of two years. As the operation was performed within the first year of the new plan, the company is not liable to pay the entire cost of the operation and offered Rs. 9300/- as per old plan.

The reason for reduction in payment was explained only after Soni sought explanation in writing after repeated non cooperation from concerned authorities. Sensing that the insurance company is totally at fault and not willing to cooperate, Soni approached CERS.

CERS on behalf of him, filed a complaint in the consumer forum on7/9/2011 seeking payment of total cost incurred for the surgery along with the litigation charges and compensation for the agony faced by Pravinchandra Soni.

After hearing both the parties, the forum headed by the President Mr. A. K. Aswani, ruled in the favor of the complainants and asked the insurance company to pay Rs.24,776/- (Rs.15000 – limit for Hernia as per old plan and Rs.9776 (extra amount charged for premium of 2 years)  with 9% interest from 7.10.2009 , Rs.2,000 towards litigation cost and Rs. 3,000 as a compensation for agony faced by Soni.