Consumer forum fines insurance firm for denying rightful health claim

The Chandigarh Consumer Disputes Redressal Forum has levied a penalty of Rs 10,000 on an insurance company for not paying the rightful claim of a city resident who had taken a health policy from the company.

Written by Express News Service | Chandigarh | Published: March 22, 2012 1:30:33 am

The Chandigarh Consumer Disputes Redressal Forum has levied a penalty of Rs 10,000 on an insurance company for not paying the rightful claim of a city resident who had taken a health policy from the company.

President of the Forum PD Goel and Members Rajinder Singh Gill and Dr Madanjit Kaur Sahota have directed the company to pay Rs 1.39 lakh to the complainant along with interest at the rate of 9 per cent per annum from the date of filing the complaint (October 2011). The Forum has also directed the company to pay Rs 10,000 to the complainant as compensation for the harassment caused to her and Rs 5000 as cost of litigation.

The order was issued by the Forum following the complaint filed by Rupinder Singh,aged 73 and his wife Amarinder Kaur,aged 68,residents of Sector 10. The couple stated that they got a mediclaim/hospitalization policy from the company in 2001,which was regularly renewed. The complainants were entitled to a cover of Rs 4 lakh each,with hospitalisation limit of Rs 50,000.

In 2011,Kaur was diagnosed with cataract of the left eye and underwent treatment in May. The couple spent Rs 85,571 on the surgery. They submitted the bill to the company but were reimbursed Rs 32,500 only. The balance amount of Rs 53,070 was rejected on the ground that the sum for multifocal lenses was non-payable.

Later,Kaur was diagnosed with cataract of the right eye,and spent Rs 53,286 on the surgery. However,the company did not reimburse the entire amount of Rs 1.39 lakh spent on the two surgeries. Aggrieved,the couple filed a case in the Forum.

In its reply in the Forum,the company stated that Kaur had opted for multifocal lens,which was not a part of the treatment. The company said these were “just to look good,as the patient did not want to wear spectacles after the surgery”. Hence,these did not fall within the scope of the policy.

The company added that as per its exclusion clause,it was not liable to make any payment for the surgery for correction of eye sight,cost of spectacles,contact lens and hearing aids etc.

After hearing arguments given by both sides,the Forum held that no exclusions or restrictive clauses were ever communicated to the couple on or after the renewal of the policy. The Forum held that eye surgery was squarely covered within the terms and conditions of the policy. No range/limit of expenses for a particular treatment was specified anywhere,said the Forum.

Also,the argument of the insurance company regarding exclusion clause for unifocal/multifocal lens was not specified anywhere in the policy. In this light,Hence,the Forum held that denying Rs 1.39 lakh to the couple amounted to unfair trade practice,and directed the company to make the payment,and also compensate them for the harassment caused to the policy holder.

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