United India to Pay Rs. 22,500 with Interest as Mediclaim

The Consumer Disputes Redressal Forum (CDRF), Ahmedabad City (Additional), found United India Insurance Company Limited guilty of deficiency in service in a mediclaim repudiation case filed by Consumer Education and Research Society (CERS) and Dr. Vipul Patadia, Ahmedabad. Allowing the complaint, the Forum ordered the insurer on 13 July 2010 to pay Dr. Patadia Rs. 22,500 within eight weeks from the date of the order plus 6 per cent interest from the date of repudiation, i.e. 31 October 2008 and Rs. 1,250 towards cost. 

Dr. Patadia had taken an individual health policy for Rs. 1,50,000 from United India Insurance Co. Ltd. at an annual premium of Rs. 5,139 from 28 February 2008 to 27 February 2009.

Five months after taking the policy, he was admitted to the Gita Maternity and Nursing Home, Ahmedabad, for right inguinal hernia and was advised operation. He was discharged four days later. He was advised complete bed rest, medical treatment and regular follow-up. His periodic visits to the nursing home for the treatment continued for about a month. Later, he was advised to resume his normal routine. The treatment cost him Rs. 46,373.

Dr. Patadia requested reimbursement from United India Insurance and expected the company not only to honour the claim but also expedite the process in view of his past claim-free record and the genuineness of his claim. He was, therefore, shocked when the insurer repudiated the claim, saying he must have submitted the claim within 15 days from the date of discharge, according to “the terms and conditions” of the policy. Dr. Patadia approached the CERS and they complained to the Forum, alleging the repudiation of the claim on wrong grounds and deficiency in service.

Dr. Patadia stated that as he had been advised complete bed rest, there had been some delay in submitting his claim. And only on this ground, the company could not repudiate the claim, he added.

The company contended that it rejected the claim according to the terms and conditions of the policy and, therefore, it could not be charged with deficiency in service. Besides, it did not find Dr. Patadia’s explanation for the delay in the submission of his claim satisfactory. His complaint should, therefore, be dismissed, pleaded United India Insurance.

The Forum concluded that Dr. Patadia, who had been medically advised complete bed rest, had satisfactorily established the valid reason for the delay. Besides, a decision is already on record that a claim cannot be rejected by taking recourse to mere technical grounds. Keeping preceding judgements of consumer courts and the Supreme Court of India in view, the Forum pronounced, “It need not be reiterated that the Consumer Protection Act is a beneficial legislation or Act and only on hypertechnical grounds the claim which is otherwise genuine should not be repudiated.”

The Forum ordered the company to pay Rs. 22,500 to Dr. Patadia with interest and cost. It decided on the payable amount as per the terms and conditions for a particular treatment of a particular ailment under the policy, i.e., in this case, 15 per cent of the policy amount of Rs. 1,50,000.

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