Karnataka: Firms told to clear senior citizen’s Rs 1.9 lakh claim for kidney treatment

BENGALURU: An insurance firm and its third-party administrator which turned down a senior citizen’s medical claim of Rs 1.9 lakh for kidney treatment claiming he was an alcoholic have been reprimanded and ordered by a consumer court to process the claim and reimburse the amount and litigation expenses within six weeks.

Former HAL aircraft division staffer and Whitefield resident Radhakrishnan K, 66, had availed medical insurance with a Rs 4 lakh cover from United India Insurance Company Pvt Ltd, for which Medi Assist India was the TPA. The mediclaim policy was part of a group policy for retired HAL employees as part of a specific scheme.

On May 31, 2017, Radhakrishnan was admitted to Narayana Multispeciality Hospital in Bengaluru following complications, including pyelonephritis, urosepsis, systematic hypertension and diabetics. He had raised a cashless hospitalisation claim. Owing to a delay in processing, he paid the hospital bills totalling Rs 1,91,847 from his pocket and got discharged.

Instead of reimbursing the amount, Medi Assist authorities on August 22, 2017 dismissed his claim, stating he was an alcoholic and an illness related to alcohol is not covered under the insurance policy. Unable to figure out the connection between a kidney ailment and alcohol, the senior citizen clarified to the firm that he only drank on social occasions and his doctors had even certified the hospitalisation wasn’t due to any alcohol-related illness.

With Medi Assist refusing to respond further, Radhakrishnan approached the Bangalore Urban District Consumer Disputes Redressal Forum on February 28, 2018 with a complaint against Medi Assist India Pvt Ltd, United India Insurance Company Pvt Ltd and HAL.

Radhakrishnan produced all records pertaining to the complaint, which Medi Assist claimed was false. Lawyers for the insurance firm and TPA argued the medical records were verified by their experts who concluded he had been an alcoholic for 25 years and the illness was due to a related complication. Therefore, the claim was rightfully repudiated, they argued.

After 19 months of court proceedings, judges of the consumer forum pointed out to Medi Assist and United India Insurance that the doctors who treated the complainant had given a discharge summary opining there was no direct nexus between the diagnosed ailments and alcohol consumption. The insurance firm and TPA’s claims appeared to be imaginary and rejection of the claim was not only arbitrary but also illegal, the judges said.

‘Pay Rs 5,000 towards litigation expenses’

In its verdict pronounced on September 21, 2019, the consumer court ordered Medi Assist India to process Radhakrishnan’s claim of Rs 1.9 lakh and forward it to United India Insurance Company, which will in turn have to credit the money to his bank account along with an additional Rs 5,000 towards his court expenses, all within six weeks. The court fixed no liability on HAL as it was only a formal party in the deal.