A consumer court has ordered an insurance company to pay Rs 2.43 lakh to a policy holder for failing to settle a lawful claim and causing immense pain and suffering to her due to its negligent act.
the goan I network
MAPUSA
Justice S Vales, President of Consumer Disputes Redressal Forum, North Goa, pulled up the officials of the health insurance company for playing with words in the insurance contract and thereby denying the rightful claim of the complainant, J Pinto, a resident of Socorro.
The complainant was suffering from blurred eye vision in the right eye. After consulting a doctor from a reputed clinic in Mumbai, she was advised to undergo ‘Ozurdex Intravitreal Implantation' procedure.
Following all due procedures, the complainant submitted her claim to the insurance company along with medical documents. Her claim was rejected on three different occasions.
The insurance company rejected the first claim on March 10, 2016, stating that the ailment did not fall under the category of day-care procedures listed in the policy.
The second claim was rejected on July 14, 2016, by email saying that the 24-hour hospitalization was not justified and could have been performed under
day care.
Similarly, a third claim was also rejected on October 24, 2016, giving reasons that the treatment could have been done on OPD basis.
When the complainant approached the grievance cell of the company, she was directed to approach the ombudsman for redressal of her grievance.
Finally, the complainant approached the consumer court on November 30, 2016, stating that the company deliberately stalled her claims and sought direction to the company to settle the same.
The insurance company told the court that there was no deficiency in service, as insurance policy was subject to terms and conditions of the insurance policy and that the eye treatment could be taken on OPD basis and without hospitalization.
The complainant produced a certified medical opinion from the All India Ophthalmological Society, which confirmed that the eye procedure had to be done under a microscope in an operation theatre and it could not be done in an OPD with overnight stay in the hospital being necessary. This was also confirmed by the Maharashtra Ophthalmological Society and Goa Medical College.
The forum observed that the company failed to produce any expert evidence that the eye treatment could be taken in OPD and without hospitalization and therefore its plea was without merit.
"The company is playing on words in the insurance contract. The main purpose of the policy is the benefit to the insured who suffer illness and who requires hospitalization for treatment on an in-patient basis or treatment defined as a day-care procedure," the forum said. It further said it did not matter whether the complainant stayed overnight in the hospital or not.
"The day-care procedure defines that due to technological advancement hospitalization for more than 24 hours cannot be mandatory requirement for availing the benefits under mediclaim policy," the forum observed.
In a stinging observation, the forum said consumers purchase mediclaim policies to cover medical emergencies and exigencies and the insurance companies should not reject the claims on whimsical and technical grounds.
Asserting that the company's repudiation of the claims was "unjustified" and "illegal", the forum said the negligent act of the company caused "immense pain" and "suffering" to the complainant. The forum directed the insurance company to pay Rs 1.73 lakh to the complainant along with interest at the rate of 18 percent per annum from March 10, 2016.
It also directed the company to pay compensation of Rs 50,000 for mental tension, agony and suffering caused to the complainant and further asked it to pay Rs 20,000 as costs of litigation.
The complainant was suffering from blurred eye vision in the right eye
She was advised to undergo ‘Ozurdex Intravitreal Implantation' procedure
The insurance company rejected three claims stating that the ailment did not fall under the category of day-care procedures listed in the policy
The consumer court observed that the company failed to produce any expert evidence that the eye treatment could be taken without hospitalization and therefore its plea was without merit
