Hospital’s enrolment under Clinical Est. Act matters in mediclaim: Consumer court

Pune: The district consumer court has ruled that an insurer cannot be held liable for deficient service for rejecting a health insurance claim on the grounds that the hospital where the policy-holder underwent treatment, was registered under the Maharashtra Shops and Establishments Act, 1948 and not under the Clinical Establishment (Registration and Regulation) Act, 2010.
The complainant had secured a health insurance policy for himself and his wife for a sum insured of Rs 3 lakh. The policy was valid from December 28, 2014 to December 27, 2015 and a premium of Rs 30,684 was paid. In February 2015, the complainant’s wife was operated at a hospital in Mumbai for which prior intimation and estimated cost was given to the insurance company. Later, he submitted a claim of Rs 79,000 that was incurred for the operation. The insurer rejected it on May 10, 2015 stating that the hospital was not registered under the Clinical Establishment (Registration and Regulation) Act, 2010.
In an order on November 7, the bench of consumer court president VP Utpat and member Onkar G Patil dismissed the complaint by a local resident who argued that the New India Assurance Company Limited had repudiated his claim for Rs 79,000 on “flimsy” and “technical” grounds that the clinic where the surgery was performed was not registered under the Clinical Establishment (R&R) Act and the same amounted to deficiency in service.
The complainant sought Rs 79,000 with 18% interest per annum since May 2015, the time when his claim was rejected, and Rs 12,000 as compensation. The insurance company argued that it was right in dismissing the claim as the hospital was was not enrolled as per the conditions mentioned in the policy agreement.
The bench referred to the insurer’s argument that the policy was a contract between two parties and the terms of the contract should be strictly construed and should be binding on both. “As per a clause in the Mediclaim 2012 Policy, a ‘Hospital’ is defined as any institution established for Inpatient Care and Day Care Treatment of illness and/or injuries and which has been registered as a Hospital with the local authorities under the Clinical Establishment (Registration and Regulation) Act, 2010 or under the enactments specified under the schedule of Section 56 (1) of the said act,” the firm had argued.
The bench held, “It is crystal clear from the documentary evidence which is produced before this Forum that the clinic where the surgery was performed is registered under the Maharashtra Shops and Establishments Act, 1948 and not under Clinical Establishment (Registration & Regulation) Act, 2010. Thus, there is breach of condition of policy. Hence, the complainant cannot claim that his insurance claim was wrongly repudiated.”

source:timesofindia