Panel directs insurance firm to pay Rs 2 lakh for denying claim

Ramkrishan Upadhyay

Tribune News Service

Chandigarh, August 23

The State Consumer Dispute Redressal Commission Chandigarh has directed an insurance firm to pay Rs2 lakh compensation to a consumer, who was denied claim on “vague reasons”.

In the complaint filed with the commission, Sukhdeep Singh Bhinder and his wife Parminder Kaur, residents of Mohali, stated that they purchased a health insurance policy “Star Family Delite” on November 30, 2018, from Star Health and Allied Insurance Company. The policy was valid from November 30, 2018 to November 29, 2019, with coverage of health insurance upto Rs.10 lakh, they added.

Bhinder said on January 14, 2019, he was taken to Fortis Hospital, Mohali, where he was admitted and his coronary angiography done. As he had got insurance policy from firm, his case was processed by hospital for preauthorisation of cashless treatment, Bhinder added.

Bhinder alleged that preauthorisation for cashless treatment at hospital was rejected by firm on the ground that in the report of coronary angiography done at Fortis Hospital on December 14, 2018, it was found that he had pre-existing disease, which fell within 30 days waiting period from the commencement of the policy. Bhinder claimed that he never visited any hospital before January 14, 2019, for coronary angiography.

Later, it was found that there was a mistake on the part of the hospital while preparing the angiography report of Bhinder. When this fact was brought to the notice of the hospital, an email was sent by it clarifying that coronary angiography of the complainant was done on January 14, 2019, and not on December 14, 2018. However, despite this clarification pre-authorisation of cashless treatment was denied to Bhinder by firm.

Complainant was given permission to apply for reimbursement of the claim amount after treatment.

Coronary artery bypass graft surgery of the complainant was conducted at the hospital for which he paid Rs4,84,499 from his pocket. The insurance company denied any deficiency on its part.

After hearing arguments the commission found the insurance firm guilty of the deficiency in services and directed it to reimburse the entire amount to the complainant spent by him on his treatment along with nine per cent interest per annum.

Besides, the firm was also directed to pay Rs2 lakh compensation for deficiency in providing service and adopting unfair trade practice.

The commission also directed the hospital to pay Rs50,000 compensation to complainant for its callous approach and negligence in maintaining record/report, which led to rejection of his claim.

The commission also told all opposite parties (firm and hospital) to jointly pay Rs35,000 towards cost of litigation to complainant.