A consumer commission has directed an insurance firm to pay Rs. 2.92 lakhs with yearly interest of 10 percent from 2014, for rejecting without proper reason, the health insurance claim of a Thane resident’s wife who had undergone a surgery at a private hospital.
The applicant Prabhakar Shirodkar’s wife started suffering back ache on June 15, 2014 and had to undergo a surgery the following day at Hiranandani Hospital. The hospital expenses came to around Rs. 2.96 lakhs. They had filed the claim with all medical papers.
The insurance firm had repudiated the claim assigning the reason that she had not disclosed a Caesarean operation and another ailment she had undergone nine-years ago, in 2005, while taking the policy. Shirodkar had approached the commission in 2017 and complained that the medical history was revealed to the firm’s panel of doctors and only then the policy was taken. He further contended that there was no connection between the illness for which surgery was required and the past medical history.
The insurance firm Apollo Munich Health Insurance Pvt. Ltd had not challenged the application before the commission. The commission said regarding this, that in its opinion the firm agrees with claims and hence has not opposed it.
Commission’s President Milind Sonawane said in the judgment of Mar 30, that there is nothing in the repudiation letter to show that the firm had asked a specific query in the proposal form regarding the ailments before giving the policy. It is of the view, it said, that there being no connection between the ailments suffered in 2005 and the surgery for which claim was raised, that only to repudiate the claim, the reason was given by the company. It held that the insurer had indulged in deficiency in service for repudiating the claim without assigning a proper reason. It ordered that it pay the applicant the claim amount with 10 percent interest per annum from Sep 2014 when the claim was repudiated. Further, it directed that considering the facts of the case, for physical and mental agony, the insurance company compensate him with Rs. 25,000 and for litigation costs, pay him Rs. 10,000.
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