District Consumer Forum Indore-II directed an insurance company to settle the claimed amount by a student and further, pay compensation for mental harassment caused due to delay and denial.
A 20-year-old student Gajanand Bais had taken a health insurance policy (medi-claim) for himself valid from November 30, 2017 to November 29, 2018.
In September 2018, Bais got sick and had to be hospitalised. He claimed amount of hospital bills under the policy, but it was rejected citing ‘Case rejected: there is no indication of hospitalisation, can be managed on OPD basis and admission is not justified’.
Bais was provided half the amount of the claimed amount, i.e. RS 25,000 out of claimed amount of Rs 50,000. “It’s amazing how now insurance companies will decide whether a patient requires hospitalisation or not,” plaintiff’s advocate Manish Zarola raised an objection in the hearing.
Following which, the doctor’s recommendation and certificate was checked. Now, the company rejected the claim stating ‘Hospitalisation for evaluation/daignostic purpose is permanently excluded from the scope of policy’.
“Bais had been suffering from fever and weakness for 3 to 4 days prior to admission in hospital, it was clearly necessary and recommended by the doctor,” Zarola justified.
The doctor treating the patient Dr P Lubana explained the court that there was a possibility of another innate serious disease, due to which, hospitalisation was suggested.
Following hearings and investigations further to verify the same, forum president Vibhagari Joshi and member Atul Jain ruled the case in favour of plaintiff.
They ordered the insurance company to pay the pending amount of Rs 32,424 to the plaintiff within two months. This amount includes compensation of Rs 5,000 provided to the plaintiff for mental harassment.
Further, the company will be required to settle consumer forum charges as well.
A 20-year-old student Gajanand Bais had taken a health insurance policy (medi-claim) for himself valid from November 30, 2017 to November 29, 2018.
In September 2018, Bais got sick and had to be hospitalised. He claimed amount of hospital bills under the policy, but it was rejected citing ‘Case rejected: there is no indication of hospitalisation, can be managed on OPD basis and admission is not justified’.
Bais was provided half the amount of the claimed amount, i.e. RS 25,000 out of claimed amount of Rs 50,000. “It’s amazing how now insurance companies will decide whether a patient requires hospitalisation or not,” plaintiff’s advocate Manish Zarola raised an objection in the hearing.
Following which, the doctor’s recommendation and certificate was checked. Now, the company rejected the claim stating ‘Hospitalisation for evaluation/daignostic purpose is permanently excluded from the scope of policy’.
“Bais had been suffering from fever and weakness for 3 to 4 days prior to admission in hospital, it was clearly necessary and recommended by the doctor,” Zarola justified.
The doctor treating the patient Dr P Lubana explained the court that there was a possibility of another innate serious disease, due to which, hospitalisation was suggested.
Following hearings and investigations further to verify the same, forum president Vibhagari Joshi and member Atul Jain ruled the case in favour of plaintiff.
They ordered the insurance company to pay the pending amount of Rs 32,424 to the plaintiff within two months. This amount includes compensation of Rs 5,000 provided to the plaintiff for mental harassment.
Further, the company will be required to settle consumer forum charges as well.