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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 - 6
The Delhi State Consumer Commission has passed judgement under which New India Assurance Company was ordered to pay Rs. 124166 in damages to one of its customers for having denied clearance for his Medicalim bills.
The Commission said the clause of "non-disclosure of pre-existing disease" for dismissing claims is applicable only when the disease and its treatment occurs immediately after taking the policy.
Setting aside an order by a district forum that had dismissed claims on Tirath Dass against The New India Assurance Co. Ltd., the commission allowed Dass" appeal.
The insurance firm had rejected Dass' claims saying that he gave false information that the disease for which he got treated was not pre-existing.
Dass had obtained a medical policy from the company on June 10, 1998. His woes began in May, 1999, when the company refused to accept his claims for expenses incurred for an operation for total hip replacement between September to December 1998.
The Company also placed on record opinion of three doctors who said Dass's disease must have started at least two years before the treatment was sought.
Das then moved a district forum but his claims were dismissed by it on December 5, 2001.
Describing the company's act as "wrong", the Commission said. "To expect a person to disclose at the time of taking a Mediclaim policy about the disease for which he had never been treated, admitted or operatedupon is too much".
Case Study - 7
NIACL to Pay Rs. 2.19 Lakh for Repudiating Mediclaim Policy
Delhi State Consumer Disputes has instructed New India Assurance Company Ltd. to pay Rs. 2.19 lakh to a man who was denied reimbursement after undergoing cardiac bypass surgery, and held it guilty of "wrongful repudiation"of the mediclaim policy on the ground of concealment of pre-existing ailments.
The Delhi State Consumer Disputes Redressal Commission while ordering the New India Assurance Company Limited (NIACL) to pay the amount said, "we cannot escape from arriving at the irresistable conclusion that disease referred to in the discharge summary was not such a disease that disentitled respondent of insurance policy. " The order came on an appeal filed by the NIACL against the order of a District Consumer Forum which, holding it guilty of wrongful, repudiating of policy of one S. K. Khosla, had asked it to pay the medical expenses in the tune of Rs. 1.74 lakh alongwith interest at the rate of nine percent from the date the same became due.
However, the Commission headed by Justice J. D. Kapoor and Member Ruminita Mittal, though upheld the Forum's verdict, did away the interest part of the award and asked the company to pay Rs. 2.19 lakh as full and final compensation including the litegation cost.
Learning from these case studies
There may be hundreds of cases, where the customer who had the proper records and courage to fight. This hasresulted in judgement being decided in their favor has gone to insurance company, consumer forum. There may be thousands, who did not go because of lack of knowledge, sufficient supporting documents not being available.. From the details you will notice that courts go into facts, records with a view to pass tojudgment.
Case Study - 8
Michael Gonsalves, Pune, June 29, 2009, Financial Chronicle
The Pune District Consumer Court has ordered the Royal Sundaram Alliance Insurance Company to pay its med claim policyholder Rs 17,897 for a nose operation, Rs 5,000 as compensation and Rs 1,000 as cost of litigation.
“Royal Sundaram Alliance Insurance Company is directed to pay the complainant Rs 17,897 with interest at 9 percent effective from April 3, 2006, when the claim was refused,” PK Gaikwad, president of Pune District Consumer Court and its members SG Joshi and JH Naik, said in their order passed on June 5.
The order also directed the insurance company to pay all amounts to the complainant Neela Ambadas Deshpande, resident of Pune, within two months. The petitioner had complained against deficiency in service and alleged fraudulent means used by the company to deny her the med claim.
Deshpande’s petition stated that she had drawn a med claim insurance policy of Rs 1.5 lakh every year from 2005 to 2007 from Royal Sundaram Alliance Insurance Company at its Law College Road, Pune branch and paid her annual premiums of Rs 3,900. The company had also sanctioned her cumulative bonus of Rs 22,500 on February 2, 2006 when she renewed her policy in that month.
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