Health Insurance: Cancer patient wins case against insurance firm
A three-year ordeal for a mumbai based cancer patient finally came to an end recently after the South Mumbai District Consumer Disputes Redressal Forum ordered an insurance company and the Third Party Administrator (TPA) to pay her the insurance amount and Rs 18,000 as compensation.Â
New India Assurance Co Ltd and TTK Healthcare TPA Private Limited will have to reimburse Sabira Virani Rs 58,049 she incurred during her treatment. The compensation of Rs 18,000 includes 9% interest on the insurance amount from June 2009 until payment and Rs 3,000 towards costs incurred in the complaint.
In 1992, Sabira’s husband Yusuf Virani had taken a policy from the insurance company, which provided cover for himself, Sabira and their two children. This policy was renewed annually. In 1993, Sabira was diagnosed with cancer in her left breast. In July the same year, she was operated upon following which she underwent chemotherapy and radiation treatment. In 1995, Sabira was hospitalized for treatment and was reimbursed by the insurance company.
New India Assurance Co Ltd and TTK Healthcare TPA Private Limited will have to reimburse Sabira Virani Rs 58,049 she incurred during her treatment. The compensation of Rs 18,000 includes 9% interest on the insurance amount from June 2009 until payment and Rs 3,000 towards costs incurred in the complaint.
In 1992, Sabira’s husband Yusuf Virani had taken a policy from the insurance company, which provided cover for himself, Sabira and their two children. This policy was renewed annually. In 1993, Sabira was diagnosed with cancer in her left breast. In July the same year, she was operated upon following which she underwent chemotherapy and radiation treatment. In 1995, Sabira was hospitalized for treatment and was reimbursed by the insurance company.
Following the treatment her health improved and she continued to visit the hospital for regular cancer check-ups. Unfortunately, in 2008, Sabira was once again diagnosed with cancer. She then underwent chemotherapy at a Mazgaon-based hospital from November 12, 2008. On December 27, 2008, Yusuf sent a claim form to the TPA and sought a reimbursement of Rs 58,000.
However, there was no response from the company or the TPA. Yusuf made several calls to both the parties and finally the TPA informed him that it did not have Sabira’s medical records prior to 2004. It further stated that without the records it was not possible to ascertain if Sabira’s illness did not exist before procuring the insurance cover.
In June 2009, the TPA sent Sabira a letter saying that the claim was rejected as she suffered from pelvic inflammatory disease since 1993 and it was a pre-existing disease as the policy was taken in 1999. Sabira sent a reply through her lawyer informing them that the policy was taken in 1992 and she never suffered from pelvic inflammatory disease.
An aggrieved Sabira filed a complaint in April 2010. The forum sent notices to the insurance company and the TPA. However, since they did not respond, the forum passed an ex parte order. The forum observed that from the documents produced by Sabira, it could be seen that the insurance company had reimbursed the claim in 1995. The forum said that the parties had wrongly repudiated the claim and held them guilty of deficiency in service.
The insurance firm and the TPA will have to pay Sabira Virani an insurance amount of Rs 58,049 and Rs 18,000 as compensation.
However, there was no response from the company or the TPA. Yusuf made several calls to both the parties and finally the TPA informed him that it did not have Sabira’s medical records prior to 2004. It further stated that without the records it was not possible to ascertain if Sabira’s illness did not exist before procuring the insurance cover.
In June 2009, the TPA sent Sabira a letter saying that the claim was rejected as she suffered from pelvic inflammatory disease since 1993 and it was a pre-existing disease as the policy was taken in 1999. Sabira sent a reply through her lawyer informing them that the policy was taken in 1992 and she never suffered from pelvic inflammatory disease.
An aggrieved Sabira filed a complaint in April 2010. The forum sent notices to the insurance company and the TPA. However, since they did not respond, the forum passed an ex parte order. The forum observed that from the documents produced by Sabira, it could be seen that the insurance company had reimbursed the claim in 1995. The forum said that the parties had wrongly repudiated the claim and held them guilty of deficiency in service.
The insurance firm and the TPA will have to pay Sabira Virani an insurance amount of Rs 58,049 and Rs 18,000 as compensation.
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