Insurer told to pay Rs 52 lakh for rejecting medical claim

In a significant order,Maharashtra Consumer Redressal Commission has directed the New India Assurance Company to pay Rs 52.07 lakh to a city resident for repudiating her foreign medical claim and deficiency in service.

Written by Agencies | Mumbai | Published: June 21, 2012 8:19:11 pm

In a significant order,Maharashtra Consumer Redressal Commission has directed the New India Assurance Company to pay Rs 52.07 lakh to a city resident for repudiating her foreign medical claim and deficiency in service.

Presiding Member P N Kashalkar ordered the insurance company to pay this amount along with interest at the rate of seven per cent per annum from the date of rejection of the claim,October 20,2010,till actual realisation,besides Rs 20,000 as costs incurred by the complainant Nina Sudhir Thackersey.

The complainant had taken an Overseas Mediclaim Policy from New India Assurance Company for USD 1,00,000 towards illness and treatment for accident for the period April 26,2010 to April 25,2011.

While on her trip to Zurich in Switzerland on May 9,2010 she complained of constant chest pain and upper abdominal pain,following which she was admitted at Klinik Hirslanden in Zurich.

At the clinic,Nina was examined by Dr Med. A Muller,Dr Henry Perschak and Dr Stefano Tresch and was subsequently admitted in the intensive care unit where she was administered dialysis. Nina was indoor patient at the clinic for 19 days,and was discharged on May 28,2010.

Nina was asked to stay back for four days and called for re-consultation on June 4,2010. On June 1,she was examined again by Dr Stefano Tresch who advised her by issuing a certificate that she should go back to India accompanied by a doctor. She returned to India on June 2,along with her husband and an Indian doctor.

Nina then filed the requisite claim with Heritage ealthcare Pvt Ltd which processes claims lodged with New India Assurance. Heritage Healthcare refused to entertain her claim on the ground that she had suffered abdominal pains due to alcoholic pancreatitis and liver cirrhosis.

The panel doctor of Heritage Healthcare was of the opinion that the complainant was treated for alcoholic pancreatitis and liver cirrhosis and that the ailments relating to alcoholism were excluded from claim and hence it was not payable.

Nina travelled again to Zurich where she met Dr Perschak and Dr Muller informing them about rejection of her claim on the ground that pancreatitis was biliary and alcoholic.

However,Dr Perschak confirmed that final diagnosis of her ailment was Idiopathic pancreatitis and ruled out possibility of liver cirrhosis. The doctors opined in writing that the assessment made by the New India Assurance Insurance Company and its panel doctor was completely “out of the blue”.

According to Dr Perschak,denial of insurance coverage of the charges was based on false judgement,insufficient medical knowledge and non-existing date.

The complainant also approached Dr Ravindra Bapat,an expert in surgical gastroenterology,who after studying her case papers along with the treatment given by the Zurich doctors,said in an affidavit that Nina Thackersey had suffered from a mild form of acute pancreatitis which recovered functionally and structurally rapidly.

“The clinical feature of the attack is not similar to alcohol induced pancreatitis,” he said.

“In the view of expert opinion given by Dr Bapat,which is further supported by the certificate issued by Dr Henry Perschak,it is crystal clear that the complainant suffered a disease ‘Idiopathic pancreatitis’ and in the course of diagnosis they were able to exclude both common causes of pancreatitis,namely biliary and alcoholic,” the Commission observed.

“We are of a strong view that the insurance company had erred in sending the repudiation letter,” it opined.

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