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Health Insurance Claim Procedures
(1) Health Insurance Claim Procedure   (2) Protect Your Interest
(3) Claim Form to be Sent to TPA   (4) Circumstances under which claims get Rejected
(5) Claims not Allowed - Some Case Studies   (6) Consumer Forum Cases in Health Insurance (Some Judgments)
5- Claims not Allowed - Some Case Studies
Case Study - 2
Deficiency in Service
Mr. Devinderpal Singh, a resident of Jamalpur, had taken a Mediclaim policy from the company for his 10-year-old son Raja. He was insured for Rs 20,000 for the period from October 13, 1998 to October 12, 1999. The complainant stated before the forum that in the first week of November, 1998, his son, felt severe pain in his abdomen. After the medical examination, a stone was found in his kidney. Thereafter, Raja was taken to the Sidhu Hospital for the treatment and there he underwent treatment in November 1998.
The complainant stated that he had spent huge amount on his treatment but could not preserve all the bills and submitted the bills for Rs 18,500.
The company pleaded that the said policy was obtained after concealment of the precious disease as the disease was pre-existing at the time of taking the policy as such the claim was not payable. The company further stated that Dr Tarsem Lal Gupta who was referred the case for the medical opinion, said Raja was suffering from pre-existing disease at the time of taking the insurance policy and as the claim fell within the exclusion clause No. 401 of the policy. The company maintained that the claim was rightly repudiated.
The forum observed, "It appears as if the father of Raja had knowledge of the disease and as such he took the policy to meet the expenses of the treatment. The forum stated that the disease was pre-existing and was not covered under the policy. The forum further added that the company had intimated the complainant that the claim lodged was considered as 'no claim' as per the rules of the policy. The forum held that there was a clear deficiency on the part of the company for not intimating the complainant.
CDRF asks OIC to make full payment of Mediclaim
Case Study - 3
The Consumer Disputes Redressal Forum recently ordered the Oriental Insurance Company to pay Rs 39,927 as Mediclaim insurance to Mr. Piyush Patel, including eight per cent interest from August 19, 1997, till realization.
In this case Mr. U.M. Raval of CDRF observed that non-disclosure of Mr. Patel's medical history like epilepsy, hypertension and backache would not amount to suppression of material facts. The OIC had repudiated the claim of reimbursement on the grounds that disease had pre-existed and the insured had concealed material facts in the proposal form itself.
Policyholder jointly filed the complaint Mr. Piyush Patel and city-based Consumer Education and Research Center for non-reimbursement of hospital expenses.
On June 7, Mr. Patel had consulted Dr Sumant Shah for backache but on June 11, after his condition deteriorated, doctor noticed paralytic effect in lower half of his body. He was admitted to Karnavati Hospital and operated for spinal cord tuberculosis.
Mr. Patel, on August 19, 1997, wrote to the OIC explaining that he was suffering from epilepsy and undergoing treatment since 1956. CERC and Mr. Patel explained that the failure to mention some minor ailment could not be construed as fraudulent suppression of material facts. Hence oriental Insurance company was ordered to pay the claim amount plus interest @8%.
Case Study - 4
CERC wins against Mediclaim renewal
A recent judgement of the Gujarat high Court directs insurance companies to renew Mediclaim policies on existing terms and condition. The Insurance Company is bound to renew the policy without excluding any diseases already covered under the existing policy even if the disease was contracted during the policy period.
Consumer Education and Research Society (CERS) filed the case on behalf of policyholders after the insurance company rejected several cases.
Case Study - 5
Insurance company told to pay Rs 75,000
The District Consumer Forum of Yamunanagar on July 11 ordered Oriental Insurance Company to pay Rs. 75574.62 and Rs 2513.05 with 12 per cent interest and Rs 5000 as compensation for harassment and litigation charges to Mr. G.D. Gupta of Mangat Pura, Jagadhri. Mr. Gupta had purchased a Mediclaim policy from the Oriental Insurance Company on November 1999. He fell ill in January 2000 and was admitted in Escorts Hospital, New Delhi for Angiography on January 29th 2000 and then in G.B. Pant Delhi for Angioplasty on February 18, 2000, while purchasing the policy, Mr. Gupta had submitted his E.C.G report and blood test report. The Insurance Company repudiated his claim by alleging that Mr. Gupta was a heart patient before the insurance of the policy as is apparent from the E.C.G report submitted by him while purchasing the policy.
The District Consumer Forum in Yamunanagar has ordered Oriental Insurance Company to pay Claim against Mediclaim Policy
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