Mediclaim – Rejection on ground of minimum 24 hour hospitalization

Mediclaim – Rejection on Ground of Minimum 24 hour Hospitalization

Cataract Surgery and several other eye surgeries are conducted in operation theaters, but are over in a few hours.
Hospitalization is actually not required.

Insurance companies routinely reject claims relating to these surgeries on the wrong assumption that minimum 24 hour hospitalization is required.

In a recent decision, the District Forum of South Mumbai has held that such claims have to be paid.

They have observed:

“We upon considering the said policy condition find that the contention raised by the Opposite Party that the claims made by the Complainant to the Opposite Party are not payable as per clause no.2.3 is totally improper. In our view in the said clause it is specifically mentioned that the limit of 24 hrs hospitalization is not applied to  specific treatments and to the eye surgery in case of stay in hospital of less than 24 hrs. provided…….

“The Opposite Party is directed to discontinue the unfair trade practice of refusing to settle claims that may be lodged in future by the Complainant No.2 for the ailment viz; Macular Oedema and the same treatment viz; Ozurdex implant subject to overall sum insured being available under the policy. “

I am giving below the link to the full decision:

 file:///C:/Users/Eleena/Downloads/judgement2015-12-08.pdf

Accident of Vehicle not having valid Registration

Narinder Singh,  purchased a Mahindra Pick UP BS-II 4WD vehicle and got it insured for  Rs. 4,30,037/- with the New India Assurance Company Ltd. for the period 12.12.2005 to 11.12.2006.

The vehicle was temporarily registered for one month period, which expired on 11.1.2006. However, on 2.2.2006, the vehicle met with an accident and got damaged.

The complainant lodged FIR and informed New India Assurance Company Ltd. about the accident., who appointed a surveyor who assessed the loss at Rs.2,60,845/- on repair basis.

However, New India Assurance Company Ltd. repudiated the claim on the ground that :
Rajeev Hetta, who was  driving the vehicle at the time of the accident, did not possess a valid and effective driving licence; and
also the vehicle had not been registered after the expiry of the temporary registration.

The complainant filed a consumer complaint before the District Forum. The District Forum allowed the complaint and directed New India Assurance Company Ltd. to indemnify the complainant to the extent of 75% of 4,30,037/- along with interest at the rate of 9% per annum thereon with effect from the date of filing of the complaint.

New India Assurance Company Ltd. preferred appeal before the State Commission. The State Commission allowed the appeal of New India Assurance Company Ltd. 

The Complainant preferred revision petition before the National Commission which was dismissed.

Thereafter, the Complainant preferred SLP before the Supreme Court. The Supreme Court did not find any infirmity in the orders passed by the State Commission and the National Commission and  dismissed the SLP.

The Supreme Court observed:

“In our view…….. using a vehicle on the public road without any registration is not only an offence punishable under Section 192 of the Motor Vehicles Act but also a fundamental breach of the terms and conditions of policy contract.”

I am giving the link to the Supreme Court Decision dt. 4 September 2014

http://judis.nic.in/supremecourt/imgs1.aspx?filename=41875

Medical Negligence – Delay in Decision

In a case of medical negligence, resulting in death of the patient, the Maharashtra State Consumer Commission has by its order dated 14 August 2015, awarded damages of Rs. 10 lakhs for negligence, interest at 9% and cost of Rs. 25,000.

This is a good decision but what is unfortunate is that the Complaint which was filed on 10.10.2002 has been finally decided on 14.8.2015.

I think every one will agree that this is too long a period. I am giving the link to the decision.

http://cms.nic.in/ncdrcusersWeb/GetJudgement.do?method=GetJudgement&caseidin=21%2F0%2FCC%2F02%2F330&dtofhearing=2015-08-14

Travel Insurance

Travel Insurance

I am publishing the following news item to show the need for taking a travel insurance while travelling abroad.

It is mandatory while travelling to certain countries.
But I would advise every tourist to take one.

Its coverage is very wide and includes medical illness, hospitalization, loss of passport, missed flights, loss of luggage, etc.

 

The following is the news item published in the Times of India (Mumbai Edition)
10 October 2013

Insurer to pay Rs 3 lakh to woman who fell ill during Thailand trip
(Rebecca SamervelRebecca Samervel, TNN | Oct 10, 2013, 01.10 AM IST)

MUMBAI: An insurance company will have to reimburse a Parel-based woman Rs 3.34 lakh assured under the overseas travel insurance policy after she fell ill on a trip to Thailand in 2011.

The complainant, Anila Gupta, will also receive Rs 15,000 as compensation as the insurer, ICICI Lombard General Insurance Company Ltd, had failed to furnish the amount when she was hospitalized abroad in Thailand.

According to the complaint filed in the Central Mumbai District Consumer Disputes Redressal Forum in 2012, Gupta said she had arrived in Thailand on July 29, 2011. However, she fell critically ill and was admitted to Bangkok hospital in August 2011. Her husband sent an email to the insurance company on August 24, 2011, and registered a cashless claim. During her hospitalization, officers of the insurance company in Bangkok were in touch with the healthcare facility and paid a substantial portion of medical expenses. However, due to an erroneous interpretation, the insurer did not make full and timely payment.

The Guptas were forced to shell out Rs 3.21 lakh from their Indian bank account in September 2011. Gupta was discharged on September 26, 2011, but could not leave Thailand as the disease was contagious and continued her treatment there as an outdoor patient. After returning to India in October 2011, she submitted her claim to the insurance company. Gupta sent a notice to the insurer on March 21, 2012, to settle the claim. However, in the absence of a response she filed the complaint.

The insurer was served a notice of the complaint but remained absent. The forum then proceeded ex parte. In the forum, Gupta produced a copy of the travel insurance. During the pendency of proceedings in the forum, she told the forum that the insurer had issued her a cheque for a part of the amount claim. However, she said that since the matter was sub judice, she had not encashed the cheque. The forum held that the insurer had not responded to the complaint and hence Gupta’s version remained unchallenged. The forum held it guilty of deficiency in service.

The full text of the decision is available at the following site:


http://164.100.72.12/ncdrcrep/judgement/21483131009162912639CC-12-127.pdf

 

Consumer Help – Mumbai

We are now ready to advise and take up consumer cases in Mumbai.

Please send us your query in brief over email….
You will get free advice..and if necessary, we will arrange for representation through a lawyer.

Binoy Gupta

eleena100@hotmail.com