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Insurance firm fined for repudiating health claim of Hoshiarpur resident
The Tribune, July 9, 2019

The District Consumer Disputes Redressal Forum has directed a private insurance company to pay Rs 12 lakh as medical expenses along with Rs 15,000 as compensation and Rs 7,000 as litigation expenses to a Hoshiarpur-based resident for repudiating his medical claim.

Manjit Kaur, a resident of Mahilpur, Hoshiarpur, had filed a complaint against Bajaj Allianz General Insurance company, alleging that he was lured into buying a health insurance policy which covered a risk insured against the hospital cash benefit and major surgical benefit.

The complainant in her complaint said she purchased the policy on June 29, 2015, for the period of six months from July 1, 2015, to December 27, 2015, and paid its premium amount on time. She said she went to Australia on July 1, 2015, and unfortunately on August 21, 2015, she fell ill and was treated by Dr Girdhari Lamba and Dr Mohan Singh at the Boulevard Medical and Acupuncture Centre, Thomastown. She got a proper treatment there.

She said her treatment at the centre continued for at least a month and she paid for all treatment availed and medicine purchased by her. Then again the complainant fell sick on December 4, 2015, and she was admitted to the Northern Hospital Radiology, Australia, and was treated for lower respiratory tract infection (pneumonia).

She said she remained admitted to the hospital from December 4 to December 8, 2015 and had spent near about $21,000 in total on her treatment, medical tests and purchase of medicine etc., which come to near about Rs 12,00,000 in Indian currency.

Manjit Kaur said she approached the Bajaj Allianz General Insurance Company and informed it about the expenses she had made on her treatment and also made claims for the reimbursement of the money spent by her on her treatment. However, the claims were rejected by the company by saying that she was diagnosed for chronic gastritis with diabetes mellitus and hypertension on August 21, 2015, and second time, the complainant was treated for lower respiratory tract infection, which was a pre-existing disease to the policy.

Meanwhile, the complainant said she sent medical certificates issued from the hospital to the insurance company wherein it had been mentioned that the disease she was treated was neither a pre-existing nor a sequel of her pre-existing conditions.

Notice of the complaint was sent to the opposite party, Bajaj Allianz General Insurance. In its reply to the forum it said “there was “Non-disclosure of material information’ by the complainant at the time of taking the insurance policy. The expenses in the present case are attributable to, arising out of, traceable to and a complication of pre-existing ailment of the complainant and not payable under the policy terms and conditions.”

After going through the facts presented by both parties, the forum in its judgment stated that non-disclosure of the previous disease had nothing to do with the disease for which the complainant underwent the treatment in the present case. Hence, the forum held the company liable and directed it to reimburse the medical treatment expenses of Rs 12 lakh, along with interest of 9 per cent per annum.

Members raise issues with minister

After going through the facts presented by both parties, the District Consumer Disputes Redressal Forum in its judgment stated that non-disclosure of the previous disease had nothing to do with the disease for which the complainant underwent the treatment in the present case. Hence, the forum held the insurance company liable and directed it to reimburse the medical treatment expenses of Rs 12 lakh, along with interest of 9 per cent per annum.

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