Continued…..
CONSUMER EDUCATION AND RESEARCH CENTRE
Cases attended and Resolved by CERC
1.
Harried
doctor gets reimbursement for eye surgery
Ahmedabad based doctor Dr. Diksha Sawant (name changed) was denied
reimbursement for an eye surgery bu Oriential Insurance Co. Ltd. CERS came to
her rescue. She had purchased the health insurance policy 20 years back and had
renewed it regularly. The policy was valid in 2009-10 when Dr. Diksha had an
eye surgery. However the insurer rejected the claim she submitted saying that
she had only received injections for macular degeneration, which was not a
surgery.
Dr. Diksha approached CERS which filed a complaint before the Consumer
Forum. It submitted that the injections had been administered under local
anaesthesia and it was a surgical procedure. For eye surgery hospitalization of
24 hours or more was not necessary for reimbursement of claim as per the terms
and conditions of the insurance policy. The forum ruled in favour of the
complainant. It ordered the Insurance Company to reimburse the cost of eye
surgery, i.e. Rs. 72,029 and also to pay interest at 8%. In addition , the
insurer had to shell out Rs. 5000 towards compensation for mental agony and Rs.
3000 towards litigation cost.
Due to oversight, the forum granted the claim for only one injunction.
The complainant will have to appeal before the State Commission to claim the
full amount of Rs. 1,44,058/-.
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2. Insurer
pulled up for denying claim saying hospital was
blacklisted
Gunvant K. Shah purchased a health insurance policy from United India
Insurance Co. Ltd. covering himself and his wife. In the first week of August
2010, his wife Rita Shah got treated for intestinal colic and gastroenteritis
at Sanjivani Heart & Medical Hospital, Ahmedabad. She was admitted on
August 5 and discharged on August 9. When Shah submitted a claim of Rs. 20,251
towards the cost of the treatment, the insurance company refused to settle the
claim saying that the hospital was in the blacklist declared by the four public
sector insurance companies. Shah was not informed about the blacklist which
came into effect on 16 August 2010.
Shah, who is a member of CERS, sought its help. CERS filed a complaint
in the Consumer Forum. As the denial of claim was not valid, the Forum ruled in
favour of the complainant. It ordered the insurance company to settle the claim
with interest at 8% from the date of rejection of the claim. In addition the
insurer was also asked to pay compensation of Rs. 3,000 for the mental agony
faced by Shah and Rs. 2,000 towards litigation costs.
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3.
CERS
takes up cudgels on behalf of elderly couple
Senior citizens based in Ahmedabad, Dinesh Dalal and his wife Sulochana,
had been joint holders of a health insurance policy of New India Assurance
Company Ltd. for more than 15 years. The cover was for Rs. 3 lakh and
cumulative bonus amounted to Rs. 1.2 lakh. In May 2010, Sulochana underwent a
knee replacement surgery at a city hospital and submitted a claim of Rs.
2,43,619, the cost incurred for surgery. However the company paid only Rs.
2,22,783 saying that Rs. 20636 had been deducted as per the revised terms and
conditions.
The elderly couple approached CERS which filed a complaint in the
Consumer Forum. CERS drew the attention to the court to the fact that the
policy was renewed without the consent and knowledge of the insured. Also, as
per a circular issued by IRDA, it was the duty of the insurance company to give
an option to senior citizens to continue a policy as per old terms and
conditions or not. As the insurer’s action was irregular, the Forum ruled in
favour of the complainant. It ordered the insurance company to pay the
complainants Rs. 20, 636/- towards the full settlement of the claim with
interest @ 9 %, Rs. 5,000 for mental agony and Rs. 2000 towards costs.
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4.
National
Insurance pays for harassing consumer
Ayesha Begum Bharti’s son had purchased a health insurance policy of
National Insurance Company Ltd. for his mother. In November 2008, Ayesha Begum,
a resident of Ahmedabad, was diagnosed with intraductal carcinoma affecting her
right breast. She had to undergo a mastectomy and submitted a claim of Rs.
70.772 for the cost of treatment. The insurance company didn’t respond- neither
accepting nor rejecting the claim.
Given the repeated refusal of National Insurance to settle the claim,
Ayesha Begum approached CERS which filed a case before the Consumer Forum
seeking total reimbursement of the cost along with compensation of Rs. 25,000
and Rs. 5,000 towards cost of litigation. After hearing both parties, the forum
passed a ruling in favour of the complainant. The insurance company’s non-settlement
of the claim was a clear indicator of deficiency in service that led to the
harassment of the consumer. It ordered the insurance company to pay 80% of the
claim amount that is Rs. 56,618 along with interest at the rate of 8%,
compensation of Rs. 10,000 for mental harassment and Rs. 5,000 towards costs.
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5.
Insurance
company forced to pay rightful claim amount
Kailash Soni had purchased a tailor made group floater Mediclaim policy
from New India Assurance Company. According to the policy, she could avail the
benefits of cashless Mediclaim at hospitals within the city. During the policy
period, Kailesh underwent a knee replacement operation at Shalby Hospitals. The
expenses incurred was Rs. 3.3 lakh. After the surgery she had to undergo
physiotherapy sessions at a spine clinic as a part of her continuing treatment
to reduce the pain. The medical expenditure incurred after operation came to
Rs. 64,450. The policy conditions clearly mentioned that the company was liable
to pay for all medical expenses up to 60 days of being hospitalized. In
Kailash’s case, she was entitled to 75% of the sum insured or claim amount, as
per the terms and conditions for joint replacement.
New India Assurance cleared the claim she submitted only partially. It
did not respond when questioned about the claim for post-operative expenses.
Kailash approached CERS which filed a case in the consumer forum against the
insurer. The Forum ruled in favour of the complainant and asked the insurance
company to pay Rs. 48,338 with 9% interest, Rs. 3000 towards mental harassment
and Rs. 1000 towards litigation expenses incurred.
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Consumer Education and Research Centre:-
Contact Details: - 079-27489945/46, 27450528, 27438752/53/ 54
Fax: - 079-27489947
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