92-yr-old Chandigarh man wins legal fight against wrongly rejected mediclaim
The insurer has been told to settle the 92-year-old Chandigarh man’s ₹29,000 hospital bill and pay ₹20,000 as compensation
Wrongly rejecting a 92-year-old man’s medical claim has cost an insurance firm dear.
Holding New India Assurance Co. Limited, Chandigarh, guilty of unfair trade practice, the District Consumer Disputes Redressal Commission-1 has directed the firm to settle the patient’s hospital bill worth ₹29,000 with interest at 9% per annum from the date of repudiation of the claim, March 15, 2022, till realisation of the same.
The firm has also been directed to pay the patient, Sita Ram, a resident of Sector 19, Chandigarh, ₹10,000 as compensation for causing mental agony and harassment, and ₹10,000 as cost of litigation.
Ram, who is able to walk only with support, approached the commission with the complaint that he bought a New India Mediclaim Policy from the insurance company by paying a premium of ₹33,223. The policy was valid from March 12, 2022, to March 11, 2023. He submitted that he had been purchasing the individual policy from the insurer regularly since 2001.
On October 23, 2021, he suffered severe back pain and was rushed to Trinity Hospital, Zirakpur, and on the advice of the doctor, he was hospitalised for supportive therapy and treatment for two days.
On discharge, he submitted the hospital bill for medical claim, but it was repudiated by the insurer, citing there was no hospitalisation.
Ram alleged that despite the fact that the claim was fully covered as per the terms and conditions of the policy, the company wrongly repudiated it, which amounted to deficiency in service and unfair trade practice.
Appearing before the commission, the insurance company claimed that there was no deficiency in service or unfair trade practice on their part. The claim was not covered under the terms and conditions of the subject policy, and was hence rightly repudiated by the company.
But after perusing the policy, the commission observed, “It is safe to hold that the case of the complainant is fully covered under the subject policy, especially as no insurance company can decide the line of treatment to be given to a patient, rather it is only the doctors who can decide about the treatment and also whether the patient was required to be admitted in the hospital or not.”
It added, “Not only this, the opinion of the doctor who treated the patient is more truthful than the TPA’s opinion that is based on examination of the case papers.”
Allowing the nonagenarian patient’s claim, the commission directed the insurer to reimburse his hospital bill.
