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Insurance firm directed to pay nursing charges to elderly
The Tribune, June 8, 2019

The Permanent Lok Adalat has directed an insurance company to pay Rs 17,000 as nursing charges and Rs 18,000 for causing mental harassment and litigation charges to a senior citizen.

Gursharan Singh Bhatia (76), a resident of Mohali, had filed a complaint against New India Assurance Company Ltd and Raksha Healthcare Insurance TPA, Chandigarh, in the Permanent Lok Adalat.

Bhatia submitted that he got mediclaim policy from the insurance firm in 2017-18. He was operated upon for bypass surgery on July 8, 2017 and stayed in hospital from June 30 to July 15, 2017.

After the surgery, he remained bedridden and was strictly advised not to move without help and for daily dressing and timely medication, he hired a nurse.

On September 29, 2017, he submitted a mediclaim bill of Rs 61,858 for surgery services, including pre and post hospital expenses. However, the insurance company settled the claim after deducting an amount of Rs 17,250 of nursing care charges.

The reason was that an exclusion clause in the insurance policy, as per which many expenses, including nursing charges during pre or post hospitalisation period were excluded. Bhatia stated that this exclusion was never brought to his notice at the time of taking the policy. Therefore, the insurance company was not entitled to withhold the amount.

He requested for a refund of Rs 17, 250 and compensation of Rs 1 lakh and Rs 20,000 as litigation charges and Rs 50,000 for mental agony. In its reply, the insurance company justified the reason for denial of mediclaim in view of the clause of the policy.

“It is seen from the reply filed by the respondent that there is no whisper of word or proof on record that the insurance policy, including exclusion clause was supplied to the applicant at the time of taking this policy or thereafter, before his admission in hospital,” observed the Permanent Lok Adalat.

The Lok Adalat observed that to hire services of nurse was indispensible. “It is held that expenses of Rs 17,250 are part of treatment and were incurred within 60 days of the post-hospitalisation and within validity period of the policy. Therefore, respondents wrongly declined the claim of the applicant.”

The Permanent Lok Adalat directed the respondents to pay Rs 17,250 with nine per cent interest from the date of submission of claim. “The applicant, who is a senior citizen was compelled to knock the door of justice at the fag end of his life. Therefore, he is entitled for compensation for Rs 10,000 for mental, physical agony and harassment and Rs 8,000 for litigation charges,” it mentioned.

Timeline

• Gursharan Singh Bhatia (76), submitted fegore the Lok Adalat that he got mediclaim policy from New India Assurance Company Ltd and Raksha Healthcare Insurance TPA in 2017-18

• Bhatia was operated upon for bypass surgery on July 8, 2017. After the surgery, he remained bedridden and for daily dressing he hired a nurse

• On September 29, 2017, he submitted a mediclaim bill of Rs 61,858. The insurance firm settled the claim after deducting an amount of Rs 17,250 of nursing care charges

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