Mumbai: The District Consumer Disputes Redressal Commission, Central Mumbai directed National Insurance Company Ltd., Lower Parel to pay Multanmal Anand Jain, a complainant Rs 4.78 lakhs medical insurance claim with six percent interest per annum from May 31, 2018 to date of realisation.
The district consumer commission that passed the order also stated that if the amount is not given within 30 days, an interest of 12 percent per annum will have to be given. Over and above, Rs 15,000 was awarded for mental agony and cost of litigation.
Insurance company fails to give reason for not paying full claim amount
The order pronounced on September 23, 2022 and uploaded on November 7, 2022 was passed by S. S. Mhatre, president and M. P. Kasar member of the District Consumer Disputes Redressal Commission.
Jain had taken a floater medical insurance cover that was issued to him on March 31, 2018. Having been insured with another person, he paid an insurance premium of Rs 15,043 with a floater sum of Rs 5 lakhs. Thereafter, he was admitted to hospital in May 2018 with chest pain, dizziness and perspiration. He incurred expenses of over Rs 5.15 lakhs. The period of Mr. Jain's hospitalization was 26.05.2018 to 31.05.2018. But the insurance company approved a claim of only Rs 33,750 and repudiated the claim of over Rs 4.78 lakhs.
The Third Party Administrator (TPA) stated that it cleared the claim as per the directives of the insurance firm Not satisfied, Mr. Jain approached the Commission and issued notices to National Insurance. Since the National Insurance failed to collect notices, considering postal track reports, the commission decided to move ex-parte on the case.
During the hearing, the commission observed that from the documents submitted, the insurance company had failed to mention specifically under which terms and conditions of the policy it approved or rejected the claims.
The commission stated, "So opposite party insurance companies failed to give proper and applicable instructions to Health Insurance TPA of India in regard to what procedure to be adopted by said TPA while evaluating the claim below policy. So by not mentioning specific terms and conditions in the claim settlement letter while settling the claim of the complainant, the opposite party insurance company has committed deficiency in services and unfair trade practices towards the complainant. The Opposing party failed to prove that, claim settled by them is bonafide. Documentary and written evidence brought before us by the complainant have remained unchallenged."
