Insurance firm to pay 1.8L for rejecting claim
Rebecca Samervel TNN
Mumbai: The South Mumbai District Consumer Disputes Redressal Forum ordered Oriental Insurance Company Ltdto pay Rs40,000 as compensation to a Thane resident who had to undergo an emergency surgery after suffering a fall in his house in 2009. The company will also have to pay him the insurance amount of Rs 1.36 lakh, after it repudiated the complainant’s claim on the grounds that he had not submitted the necessary documents.
The complainant, Kirit Mehta, and his family were insured with the company and he was assured of Rs 2 lakh.
On April 1, 2009, Mehta sustained an injury and kept vomiting throughout the day. Two days later, he had to be admitted to a Thane hospital where he was operated upon. Due to the heavy expenses incurred there, Mehta asked to be discharged on April 11, 2009. He then took admission to another hospital where he continued his post-operative treatment till April 24, 2009.
In June, he filed his claims with the insurance company through a third party agent, Raksha TPA. Despite regular follow-up, Mehta got no responseeither from the TPA or the insurance company. Aggrieved, he lodged a complaint in the forum in 2011.
The insurance firm contended that Mehta had suppressed material facts and did not submit all the documents required, in spite of several requests. The forum, however, observed that Mehta did indeed submit all the required papers like the discharge certificates of the hospitals, surgeon’s certificate and bill receipts.
The forum also said a letter, dated March 10, 2010, showed that the TPA had closed the claim. The forum observed that the contents of the letter were inconsistent and contradictory.
Stating that the file was closed without application of mind and unjustly, the forum said, “The opposite partiestreatedthesameletter as a first reminder as well as a second reminder. In the same letter, it is stated that the file was closed. Rejection of claim without application of mind amounts to deficiency in service.”
The complainant, Kirit Mehta, and his family were insured with the company and he was assured of Rs 2 lakh.
On April 1, 2009, Mehta sustained an injury and kept vomiting throughout the day. Two days later, he had to be admitted to a Thane hospital where he was operated upon. Due to the heavy expenses incurred there, Mehta asked to be discharged on April 11, 2009. He then took admission to another hospital where he continued his post-operative treatment till April 24, 2009.
In June, he filed his claims with the insurance company through a third party agent, Raksha TPA. Despite regular follow-up, Mehta got no responseeither from the TPA or the insurance company. Aggrieved, he lodged a complaint in the forum in 2011.
The insurance firm contended that Mehta had suppressed material facts and did not submit all the documents required, in spite of several requests. The forum, however, observed that Mehta did indeed submit all the required papers like the discharge certificates of the hospitals, surgeon’s certificate and bill receipts.
The forum also said a letter, dated March 10, 2010, showed that the TPA had closed the claim. The forum observed that the contents of the letter were inconsistent and contradictory.
Stating that the file was closed without application of mind and unjustly, the forum said, “The opposite partiestreatedthesameletter as a first reminder as well as a second reminder. In the same letter, it is stated that the file was closed. Rejection of claim without application of mind amounts to deficiency in service.”
Source:::: The Times of India, 24-09-2012, p.02. http://epaper.timesofindia.com/Default/Client.asp?Daily=TOIM&showST=true&login=default&pub=TOI&Enter=true&Skin=TOINEW
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