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Insurer pays for hush-hush policy tweak, claim denial - Consumer Forum

An insurance company cannot make changes unilaterally or surreptitiously to the disadvantage of the insured, observed a consumer forum as it directed the New India Assurance Company Ltd to pay the insured amount of Rs 1.59 lakh along with Rs 69,000 compensation to a Chowpatty-based man, Kaushik Pandya, after it wrongly repudiated his wife's mediclaim.

Pandya had told the forum that he had obtained information under the RTI Act about the number of claims received and paid by the insurance company for treatment similar to that undergone by his wife.

"It was revealed that of the total 125 claims reported, the company had paid 28 claims and rejected 97 during the year 2009-10," he said.

Pandya told the forum that his wife, Rupa, suffered from age-related macular degeneration in her left eye from 1989 and was unable to see with that eye.

In 2009 Rupa had to undergo treatment for the illness in her right eye, which remained bandaged for 24 hrs. As she also suffered from hypertension and diabetes, she was admitted to a hospital on doctors' advice.

When Pandya filed for insurance, it was rejected. He filed a complaint in the forum on October 29, 2010.

The insurance company contended that the claim was denied as the treatment fell outside the scope of the health policy. It stated that in the case of the specific disease, there was no need for hospitalization. The company contended that though the treatment injection is given in the operation theatre, in view of the nature of treatment it falls outside the scope of health policies.

The forum observed that rejection of the claim was based on a circular dated February 9, 2009, which excluded the treatment. The forum said that the circular was an internal one and Pandya had rightly submitted that as he was not privy to it and it could not be binding on him.

"We hold that the repudiation made by the opposite party regarding the claim lodged by the complainant about the treatment provided by admitting his wife in the hospital and therefore, not payable is not justifiable," the forum said.

Article referred: http://articles.timesofindia.indiatimes.com/2013-06-16/mumbai/40006224_1_consumer-forum-claim-denial-insurance-company

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