LUDHIANA: The district consumer forum has penalized an insurance company for not reimbursing medical expenses of a businessman covered under the medi claim policy. The forum directed Bajaj Allianz General Insurance Company, Viman Road, Pune, through its general manager and manager of the company’s Feroze Gandhi market branch to pay a compensation of Rs 25,000 for mental harassment and agony and Rs 5,000 as litigation expenses in favour of the complainant.
Forum president G K Dhir and member Param Jit Singh Bewli directed the opposite party to reconsider the claim of the complainant, settle the same and pay the due amount within 40 days from the date of the receipt of the copy of the order. It added that the amount of the bill dated November 11, 2013, be excluded from the payable amount. The forum added that in case the payment was not made within 40 days, then the complainant would be entitled to the due amount by opposite parties with an interest at the rate 7% per annum from the date of the complaint that was received .
In his complaint, Rajnesh Kumar of Sector 39, Chandigarh Road, had stated that he had and obtained a mediclaim insurance policy from Bajaj Allianz General Insurance Company, Viman Road, Pune, through its branch office at Ludhiana with validity until October 29, 2015. He added that his health started deteriorating from December 8, 2013. The complaint stated, “Due to this, the complainant was shifted to Sachdeva Nursing Home, Ludhiana, where doctors started giving medical aid at once. The complainant remained admitted in that hospital until December 16, 2013. The facility of an AC room at the rate of Rs 2,500 per day for five days was availed by the complainant. He was later was shifted to the ICU for three days. Later on medical tests suggested by the doctors were done by the complainant and an amount of Rs 81,835 in spent by the complainant during hospitalization. Thereafter, the complainant approached the opposite party for reimbursement of these expenses. However, the insurance company kept on procrastinating the matter. In one of the letter written by the employees of the company, the complainant is mentioned as dead and the said mistake cast a shadow in the mind of the complainant about working capability of the opposite party. Despite sending repeated emails to the firm with the request to satisfy his claim, it failed to give any reply to the same and as such, by pleading deficiency in service on the part of the insurance company, a prayer was made for directing the firm to reimburse the medical expenses of amount of Rs 81,835 with interest at the rate 18% per annum. Compensation for mental pain and agony of Rs 1 lakh was also claimed.”
In joint written statement filed by the insurance company’s main office at Pune and Ludhiana branch. it was stated that after the receipt of the claim intimation, they had appointed an investigator for ascertaining genuineness of the claim and received a report on February 17, 2014. Through that report, it was pointed out that certain discrepancies and lapses found in the claim documents. After the receipt of the documents and the investigator report, the company scrutinized the documents and declined the claim of complainant on February 20, 2014, finding that hospitalization of the complainant was for investigation and treatment of acute febrile illness with dengue fever only and in view of discrepancies and lapses in the claim documents, claim is not payable.
The judgment said an otherwise genuine claim of insurance should not be rejected on flimsy and technical grounds as it would erode the trust of people in the insurance companies. It added that the consumer forums were not expected to go in the technicalities of the civil or criminal jurisprudence because consumer disputes were to be decided on yardsticks of reasonableness, probability and by applying with full force the principles of natural justice.
The judgment added that the discrepancies pointed out by the deponent tendered in evidence affidavits did not exist or they were of ordinary nature and bound to exist when a version travels from one mouth to other and as such, repudiation of claim ordered in this case is on flimsy and technical grounds alone. Being so, complainant entitled to somewhat hefty amount of compensation for mental harassment and agony along with litigation expenses, so that such like genuine claim of insurer may not be rejected by unscrupulous or harsh insurer.