Insurance company ordered to reimburse patient damages of Rs. 3Lakh

A district consumer commission has ordered an insurance company to reimburse Rs 2.65 lakh plus compensation of Rs 2.70 lakh to a 55-year-old Colaba woman who had undergone a pacemaker replacement surgery at a prestigious South Mumbai hospital in 2019. The commission chastised the insurance company for its excessively technical approach and adherence to a "pick and choose" theory.

The claim was denied by the firm due to the discharge report mentioning that the issue was merely a "pacemaker battery replacement." The commission highlighted, however, that further documentation confirming the pacemaker replacement and another discharge statement verified by the attending surgeon corrected the erroneous line.

"Therefore, the discharge summary contains the arbitrary order of claim repudiation based on incorrect phrase interpretation. Therefore, the committee concluded that the order of repudiation was unsustainable under the law.

On August 28, 2019, Shauheen and Muneera Daya filed a complaint with the commission against Genins India Insurance TPA Ltd. and The United India Insurance Co Ltd. According to Shauheen's submission, he bought the policy in September 1998 for himself, his wife, and their daughter. The policy was periodically extended.