A health insurance company in Ludhianawas penalized for not settling the medical claim of a policy holder by the district consumer disputes redressal forum.

The Religare Health Insurance Company Limited has directed to settle the claim amount of Rs 32,906.Theforum — comprising its president G K Dhir and member JyotsnaThatai has also issued directions to the company to pay Rs 2,000 as composite compensation for mental torture and harassment, as well as litigation expenses to Pankaj, a resident of Hira Nagar on Kakowal Road.

Pankaj gave a complaint to the forum on June 6, stating that he had taken a health insurance from Religare Health Insurance Policy in his name. The firm guaranteed reimbursement of incurred expenses in case of medical emergencies. On February 3 2018, the complainant was admitted in Mohan Dai Oswal Hospital, as he was under the influence of ketamine.

The complainant was discharged from the hospital on February 4 last year and an amount of Rs 31,264 was incurred as medical expenses on his treatment. He submittedhis medical claim which was rejected through a letter received by Pankaj on March 5 last year. Though, earlier in 2017, he got a similar treatment and his claim was sanctioned by the insurance company. By appealing that the insurance company failed to perform their part of the contract, and by claiming that deficient services were provided by it, he filed for reimbursement of incurred medical expenses, along with compensation for mental torture and harassment of Rs 50,000, and litigation expenses of Rs 22,000.

The insurance company appeared through a counsel, and without filing for a written reply, an offer was given on October 29, to the effect that it was ready to resolve the claim by paying the amount of Rs 32,906 as full and final claim settlement within 30 days from the receipt of copy of the order. The offer was accepted by Pankaj on November 7, but with a rider that the amount of compensation and litigation expenses should also be added. Thus, practically the dispute remained as to whether or not Pankaj was eligible to any amount of compensation and litigation expenses.

The forum witnessed that without filing a written statement, an offer was made, which was also accepted. Also, it showed the anxiety of the insurance company to settle the claim as early as possible by not dragging the complainant Pankaj in further litigation.

The forum observed that the offer been made before filing of the complaint or claim, hence the occasion with the complainant to file the complaint was not there. Also, no copy of the repudiation letter was produced on record by the complainant. In this false plea taken in the complaint, there was need to grant lesser amount of compensation and litigation expenses. The insurance company by giving an offer tried to diminish the sufferings of complainant. The forum allowed a composite amount of Rs 2,000 as compensation for mental torture and harassment and litigation expenses.

Source: ET Healthworld