A district consumer court in Ahmedabad has ordered the United India Insurance Company to pay for the cost of surgeon for the medical treatment of a claimant, said a statement from Ahmedabad-based Consumer Education and Research Society (CERS). The insurance company had earlier refused to bear the cost and did not relent even after repeated requests.
Ahmedabad-based Deepa Sonpal had obtained a mediclaim policy with an insured sum of Rs 2.75 lakh from the United Insurance Company Ltd. in 2002. She had paid the premium regularly for 10 years. In 2012, she underwent a surgery for cyst removal and laparoscopic hysterectomy at Shrey Hospital in Ahmedabad.
The surgeon, Dr Mukesh Bavishi, asked her to pay his fee of Rs 1 lakh separately and gave her a receipt. Deepa submitted a claim for Rs1.19 lakh. To her shock, the Third Party Administrator (TPA) Med Save Health Care sanctioned payment of Rs 14,571. The reason given was that some of the items were not payable as per policy conditions.
As per the policy terms, actual expenses incurred on a hysterectomy or 25% of the sum insured, whichever was less, would be paid by the insurance company. So, Deepa was entitled to payment of 25% of Rs 2.75 lakh which comes to Rs 68,750. Instead, the insurer had paid only Rs 14,571, having arbitrarily deducted Rs 54,179.
As her repeated efforts to include doctor's fee in the claim did not bear fruit, she approached CERS, which filed a case at Ahmedabad district consumer court.
After hearing both the parties, the court recently ruled in favour of the complainant and directed the insurance company to pay Rs 54,179 with 9% interest within 30 days from the date of order. The forum also ordered the opposite party to pay Rs 5,000 as compensation for mental harassment and agony caused and Rs 3,000 towards litigation costs.
"Our argument was how can one be given medical treatment without a doctor. So the fees paid to the doctor definitely fall under the insurance claim. The court ruled in our favour," said Pritee Shah, chief general manager of CERS.
THE CLAIM
- Deepa Sonpal had obtained a mediclaim policy of Rs 2.75 lakh.
- She had paid the premium regularly for 10 years.
