Health Insurance : Consumer Forum directs insurance company to pay Rs 5.5 lakh

The Maharashtra State Consumer Disputes Redressal Commission ordered New India Assurance Co Ltd to pay Rs 3 lakh to a Malad resident, 14 years after she underwent a bypass surgery and the company repudiated her claim. The insurance company will also pay the victim, Rama Shetty, a reimbursement amount of Rs 2.56 lakh.

Shetty said she developed chest pains for the first time in November 1998 and on the family doctor’s advice, she was referred to an expert for examination. On November 16, 1998, she underwent a coronary angiography. She contended that she had subscribed to a mediclaim policy jointly with her husband and the sum assured was Rs 3 lakh.

On December 7, 1998, Shetty was hospitalized and underwent a coronary bypass surgery to remove a clot. She was discharged on December 18, 1998, and later filed a claim for reimbursement of hospital expenses amounting to Rs 2.56 lakh.

The insurance company repudiated the claim on the grounds that Shetty had a pre-existing disease for two years prior to hospitalization. This repudiation, they said, was based on the expert opinion of the panel doctor of the insurance company. Shetty then filed a compliant in the forum.

The insurance firm denied the contention by filing an affidavit of evidence and relied on medical summary obtained through its investigator. The company reiterated that the repudiation is justified as the panel doctor’s opinion is on record to show that Shetty had pre-existing chest pain. The forum, in its order, said that the insurance company remained absent at the time of hearing and the order was passed in its absence.

Shetty, however, told the forum that when she underwent a medical examination on December 2, 1997, no abnormality was noticed with respect to chest pain.

The forum stated that the insurance company had not filed the documentary evidence, including the report of the panel doctor as required under a section of the Consumer Protection Act. “Therefore, the decision of repudiating the claim based on these experts’ opinion cannot be taken as validly acted upon,” the forum held.

 

Rebecca Samervel, TNN http://timesofindia.indiatimes.com/city/mumbai/Malad-woman-takes-on-insurance-firm-gets-rs-5-5-lakh/articleshow/12408372.cms