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Mediclaim can’t be rejected if original bills are lost and and duplicates submitted
Times of India, February 03, 2019

MUMBAI: In a significant order, a consumer forum has held that in case of loss of original hospital papers and bills in a medical claim, the insurance company cannot repudiate the claim on the grounds that duplicate bills were submitted.

Coming to the rescue of a Bandra doctor, Satyapriya Dhabuwala, who was hopitalised after suffering a brain haemorrhage in 2012, the district forum has ordered New India Assurance Co Lt and Health India TPA Services (I) Ltd, to pay Rs 2.21 lakh compensation (reimbursement of Rs 1.71 lakh and rest as interest and costs).

The consumer forum pointed out that Dhabuwala had been purchasing the insurance policy since 2004 and also renewing it by paying the annual premium. “It also appears duplicate bills have been produced by the complainant to insurer as originals were lost by him. Opposite party (insurance company) has failed to prove how appropriate duplicate bills are not applicable for filling the claim in case originals get lost,” the forum said.

The forum further stated it was evident the insurance company had not considered the claim reasonably. “Such an act is negligence and deficiency in service and unfair trade practice,” the forum said.

Dhabuwala moved the South Mumbai District Consumer Disputes Redressal Forum in 2014. He said he was hospitalized between February 8 and 19, 2012

Dhabuwala Further stated after he submitted the claim with the duplicate bills, the third party administrator sent him a letter in March 2014 and informed him he had to provide the original bill with detailed break-up and original cash bill receipts. He submitted he immediately wrote to them with details about misplacing original bill and also requested them to condone the delay due to the cerebral haemorrhage he had suffered which had affected his memory and mental faculties. He also stated there was no one else in the family who could have submitted the claim.

However, in April 2014, the third party administrator informed him the claim was rejected as there was a delay 703 days.

Dhabuwala moved the forum in October 2014

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