Ludhiana: Insurance firm told to pay Rs 34k for failing to settle medical claim

Ludhiana: The district consumer disputes redressal forum has penalised a health insurance company for not settling the medical claim of a policy holder. Apart from directing the Religare Health Insurance Company Limited to settle the claim amount of Rs 32,906, the forum — comprising its president G K Dhir and member Jyotsna Thatai — also issued directions to the company to pay Rs 2,000 as composite compensation for mental agony and harassment, as well as litigation expenses to Pankaj, a resident of Hira Nagar on Kakowal Road.

On June 6, Pankaj gave a complaint to the forum stating that he had taken a health insurance from Religare Health Insurance Policy in his name. The firm assured reimbursement of incurred expenses in case of medical emergencies. On February 3 last year, the complainant was admitted in Mohan Dai Oswal Hospital, because he was under the influence of ketamine.

The complainant was discharged from the hospital on February 4 last year. An amount of Rs 31,264 was incurred as medical expenses on his treatment. On submission of the claim, it was rejected through a letter received by Pankaj on March 5 last year. However, earlier in 2017, when he got a similar treatment, then his claim was sanctioned by the insurance company. By claiming that the insurance company failed to perform their part of the contract, and by claiming that deficient services were provided by it, he filed for seeking reimbursement of incurred medical expenses, along with compensation for mental agony and harassment of Rs 50,000, and litigation expenses of Rs 22,000.

The insurance company appeared through a counsel, and without filing a written reply, an offer was given on October 29, to the effect that it was ready to settle the claim by paying the amount of Rs 32,906 as full and final claim settlement within 30 days from the receipt of copy of the order. That offer was accepted by Pankaj on November 7, but with a rider that the amount of compensation and litigation expenses should also be allowed. So, virtually the dispute remained as to whether or not Pankaj was entitled to any amount of compensation and litigation expenses.

The forum observed that without filing a written statement, an offer was made, which was accepted. As such, it showed the anxiety of the insurance company to settle the claim at the earliest by not dragging the complainant Pankaj in further litigation. “In view of that, certainly a lenient view required to be taken in the matter of imposition of costs of litigation and compensation amount for harassment. Rather, the insurance company avoided harassing the complainant, and that is why an offer for settlement given immediately after appearance by the counsel for the insurance company.

The forum observed, “However, had that offer been made before filing of the complaint or claim, then the occasion with the complainant to file the complaint was not there. No copy of the repudiation letter was produced on record by the complainant. In view of this false plea taken in the complaint also, there is need to grant lesser amount of compensation and litigation expenses. The insurance company by giving an offer tried to mitigate the sufferings of complainant, and as such allowing a composite amount of Rs 2,000 as compensation for mental agony and harassment and litigation expenses will be sufficient.”