Forum tells risk firm to pay medical claim of insured

The District Consumer Dispute Redressal Forum of south Mumbai pulled up an insurance company for rejecting the complainant’s medical claim and directed the firm to pay the complainant’s medical bills worth Rs 38,015 along with an additional amount of Rs 10,000 towards the complainant’s mental agony. The forum also asked the firm to pay the complainant’s litigation costs. Explaining its rejection, the firm stated that there was no need for the complainant to get continuous medical supervision after undergoing gastroscopy.

Vasantray Mody, a resident of New Queen’s Road at Opera House, had purchased a mediclaim policy from The Oriental Insurance Company. He had purchased the individual medical insurance policy and paid an approximate one-time premium of Rs 1.5 lakh. The policy was valid from March 20, 2013 to March 19, 2014. In the interim, Mody was advised by doctors to undergo an operation and was hospitalised for the same. He underwent gastroscopy and later submitted the hospital bills seeking reimbursement for his medical treatment.

The insurance firm refused to reimburse the bills claiming that as per the norms of the policy, the complainant is not entitled to take hospitalisation for more than 24 hours, and since it was exceeded, the claim was repudiated.

The forum, after going through the evidence brought in the record, held, “When the complainant submitted the claim, it was repudiated on March 5, 2014. As the complainant had paid the premium of the policy and the policy was in existence, therefore, we found that there is a deficiency in service and unfair trade practice on the part of the insurance firm as it repudiated the claim of the complainant without any reasonable cause.”