Indore (Madhya Pradesh): District Consumer Forum Indore-II directed an insurance company to settle the amount claimed 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 (mediclaim) for himself valid from November 30, 2017, to November 29, 2018.
In September 2018, Bais fell ill and had to be admitted to hospital. He claimed the 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, that is, Rs 25,000 out of the total 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 at the hearing.
Following this, 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 to the hospital and it was clearly necessary and recommended by the doctor,” Zarola justified.
The doctor treating the patient, Dr P Lubana, explained to the court that there was a possibility of another innate serious disease, due to which hospitalisation had been suggested.
Following hearings and investigations further to verify the same, forum president Vibhagari Joshi and member Atul Jain ruled the case in favour of the 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 the consumer forum charges, as well.
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