PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF KARNATAKA
(UNDER RULE NO: 17 of THE INSURANCE OMBUDSMAN RULES, 2017)
OMBUDSMAN- NEERJA SHAH
In the matter of: Mr. S S SATISH V/s UNITED INDIA INSURANCE COMPANY LTD
Complaint No: BNG-H-051-2021-0385 to 0391, 0393
Award No: IO/BNG/A/HI/0244 to 0251/2020-21
1
Name & Address of the Complainant
Mr. S S Satish
# 538, 5
th
Main, Vijaya Bank layout,
Bannerghatta Road
BENGALURU – 560 076
Mobile # 9449003535
E-mail: [email protected]
2
Policy No.
Type of Policy
Duration of Policy/Policy Period
5001002819P112575620
IBA Policy – BoB Employees
01.11.2019 to 31.10.2020
3
Name of the Insured/ Proposer
Name of the policyholder
Mrs. S S Jyoti – Spouse
IBA Policy - Bank Of Baroda
4
Name of the Respondent Insurer
United India Insurance Company Limited
5
Date of Repudiation
17.01.2020
6
Reason for repudiation/rejection
Treatment not listed under allowed list of Day Care
procedures
7
Date of receipt of Annexure VI A
28.10.2020
8
Nature of complaint
Rejection of medi-claim
9
Amount of claim
₹. 2,54,272/-
10
Date of Partial Settlement
NA
11
Amount of relief sought
₹. 2,54,272/- + Interest
12
Complaint registered under Rule no
13 (1) (b) of Insurance Ombudsman Rules, 2017
13
Date of hearing/place
23.12.2020 / Online VC
14
Representation at the hearing
a) For the Complainant
Self
b) For the Respondent Insurer
Ms. H A Pannaga, Dy Manager
Dr Komal Shinde, TPA
15
Complaint how disposed
DISALLOWED
16
Date of Award/Order
08.01.2021
17. Brief Facts of the Case
The complaint emanated from the rejection of the claim on the grounds that standalone
administration of inj. Bevatas is not payable under allowed list of day care procedures as per
policy terms and conditions. Hence, the Complainant approached this Forum for settlement of
claims.
18. Cause of complaint:
a. Complainant’s argument:
Complainant alongwith his wife (Insured Person – hereafter referred as IP) was covered under the
Employer provided GMC policy issued by RI vide policy number 5001002819P112575620 from
01.11.2019 to 31.10.2020. In Jul 2018, IP was diagnosed with Ovary Cancer. She was advised 6
chemotherapy cycles and 17 cycles for Adjuvant Chemotherapy. Injection Bevatas was
administered under the Adjuvant chemotherapy regime to the IP on various occasions at Sri
Shankara Cancer hospital & Research Centre. He was having one more health policy from RI vide
policy no 0726002818P113957782 wherein adjuvant chemotherapy treatment (Adminsitration of
Inj Bevatas) was paid for the period 19.06.2019 to 16.11.2019. However same treatment was
rejected for 11
th
cycle and onwards under the Group policy issued by RI under IBA Policy. He
submitted that treatment was prescribed oncologist, yet his genuine claim has been denied by RI.
Hence he requested intervention of the Forum for resolution of his grievance.
b. Insurer’s argument:
The Respondent Insurer, in their Self Contained Note dated 14.12.2020 sent on e-mail dt
15.12.2020, whilst confirming the policy issuance and rejection of claims, submitted that the IP
was administered Inj. Bevatas at Sri Shankara Cancer hospital & research Centre on various
occasions. As per IP’s medical records, she was given standalone dosage of Bevatas injection and
the hospitalisation was for less than 24 hours on each occasion. RI submitted that Inj. Bevatas is
type of immunotherapy. Immunotherapy works by encouraging the body's own immune system
to attack the tumor cells and stop the growth of cancer. Immunotherapy is payable only if it forms
a part of inpatient treatment in case of hospitalization or part of discharge advice upto the limits
for post hospitalization. However it is not payable if hospitalization is done only for administration
of medicine/drugs. Policy covers parenteral chemotherapy under list of allowed day care
procedure as per clause 3.3 of policy terms and hence the claims were repudiated as per terms
and conditions of the policy.
19. Reason for Registration of complaint:
The complaint falls within the scope of the Insurance Ombudsman Rules, 2017 and so, it was
registered.
20. The following documents were placed for perusal:
a. Complaint along with enclosures,
b. SCN of the Respondent Insurer along with enclosures and
c. Consent of the Complainant in Annexure VI-A and Respondent Insurer in VII-A.
21. Result of the personal hearing with both the parties (Observations & Conclusions):
The issue which require consideration is whether the treatment is payable under clause 3.3 Day
Care Treatment list of the policy terms and conditions. The Forum has perused the documentary
evidence available on record and the submissions made by both the parties.
Personal hearing by the way of online Video-conferencing through Goto Meet was conducted in
the said case. Mr Satish (Complainant) and Ms. H A Pannaga along with Dr Komal
(Representative(s) of RI) presented their case. Confirmation from all the participants about the
clarity of audio and video was taken and to which the participants responded positively.
During the Personal Hearing, both the parties reiterated their earlier submissions.
From the submission made by complainant in his complaint and documents available on record,
Forum observes that IP was diagnosed as Primary peritoneal Carcinoma - Stage 4. She underwent
3 chemotherapy cycles on 27.11.2018, 18.12.2018 and 08.01.2019 at Basavatarakam Indo-
American Cancer Hospital & Research Institute, Hyderabad. Thereafter she had a major surgery
(optimal interval cytoreduction) on 18.02.2019. Thereafter she was hospitalised on 25.03.2019 to
26.03.2019 at Sri Shankara Cancer Hospital & Research Centre, Bengaluru and received 4
th
cycle of
chemotherapy as per Paclitaxel/Carbolatin regimen. It is pertinent to note here that Discharge
Summary of this hospitalisation reveals that Inj Bevacizumab was to be added from 5
th
cycle
onward for total of 1 year. Her Discharge Summary dt 27.05.2019 of Basavatarakam Indo-
American Cancer Hospital & Research Institute, Hyderabad reveal that she has completed 6 cycles
of chemo with Inj Pacil and Inj Carboplatin and was administered Inj Bevatas and methotraxat.
Thereafter she was treated at Sri Shankara Cancer Hospital & Research Centre, Bengaluru.
Discharge Summary of Sri Shankara Cancer Hospital & Research Centre, Bengaluru reveals that IP
was now planned to receive chemotherapy as per Bevacizumab regimen.
Present dispute is with regard to claim for cycle 11 to 17 of the planned treatment. The details of
claims disallowed under the policy are given below:
S. No
Claim No & Date of Hospitalisation
Amount
1
21208836 dt 02.12.2019
Rs 40,144/-
2
21271883 dt 20.12.2019
Rs 39,995/-
3
21523098 dt 10.01.2020
Rs 39,900/-
4
21611704 dt 01.02.2020
Rs 41,610/-
5
21782603 dt 20.02.2020
Rs 39,933/-
6
22141038 dt 21.03.2020
Rs 3,812/-
7
22116269 dt 02.04.2020
Rs 38,878/-
8
22306052 dt 06.06.2020
Rs 10,000/-
Web study reveals that Bevatas (also sold as Inj Bevacizumab or Inj Avastin) is recombinant
humanized monoclonal antibody. It is administered along with chemotherapy to treat cancer that
has spread to other parts of the body that cannot be removed by surgery, or has returned after
treatment with other chemotherapy medications. Bevacizumab injection products are in a class of
medications called antiangiogenic agents. They work by stopping the formation of blood vessels
that bring oxygen and nutrients to tumors which slows the growth and spread of tumors. In
contrast Chemotherapy drugs attack fast-growing cells, like cancer cells directly.
Further study reveals that Avastin, in combination with carboplatin and paclitaxel, followed by
Avastin as a single agent, is indicated for the treatment of patients with stage III or IV epithelial
ovarian, fallopian tube, or primary peritoneal cancer following initial surgical resection. The
scrutiny of medical bills of the IP reveals that Dexona-Cort-S injection was used along with Inj.
Bevatas. People with cancer undergoing chemotherapy are often given dexamethasone to
counteract certain side effects of their antitumor treatments. However none of the
aforementioned drugs are classified as chemotherapy drugs.
The Forum takes cognisance of clarification letter dt 02.12.2019, 20.12.2019, 10.01.2020,
02.04.2020 issued by treating doctor which stated that Bevacizumab was administered as a
chemotherapeutic agent. However the pharmacy bills submitted for aforementioned dates did
not establish that Inj Bevatas was purchased along with any other chemotherapeutic drug for
administration on IP. It was not clear from the Discharge Summary of IP if Inj Bevacizumab was
given as standalone medication or along with other chemotherapeutic agents as per Bevacizumab
regimen. Thus time was given to complainant to produce clarification letter from doctor regarding
the nature of treatment given to IP to ascertain the facts of the case. Complainant vide mail dt
08.01.2020 produced the clarification certificate dt 05.01.2021 from treating doctor stating that
17 doses of Inj Bevacuzimab alone were administered to IP from 27.05.2019 to 02.04.2020.
Thus it is clear that standalone administration of Inj. Bevatas or in combination with Dexona-Cort-
S Inj. is distinct from chemotherapy. Only certain defined medical procedures are permitted under
Day care procedures clause 3.3 including Parenteral Chemotherapy and Radiotherapy.
Further, since administration of injection Bevatas does not involve any anaesthetic administration,
the said treatment is not covered under the definition of Day Cay procedure under clause 2.10 -
“Day care Treatment means the medical treatment and/or surgical procedure which is
i. undertaken under general or local anaesthesia in a hospital/day care centre in less
than 24 hours because of technological advancement, and
ii. Which would have otherwise required a hospitalisation of more than 24 hours.
Treatment normally taken on an outpatient basis is not included in the scope of this
definition.”
Complainant contested that previous claim for standalone administration of Bevatas Injection was
allowed by RI under a different policy. Since the claims have been paid by RI under that policy, the
Forum does not wish to interfere with the decision of the RI and restrict its scope to present policy
under dispute.
Hon’ble Supreme Court of India in the case of Suraj Mal Ram Niwas Oil Mills (P) Ltd. v. United
India Insurance Co. Ltd. & Anr., interalia held that:
“Before embarking on an examination of the correctness of the grounds of repudiation of
the policy, it would be apposite to examine the nature of a contract of insurance. It is trite
that in a contract of insurance, the rights and obligations are governed by the terms of the
said contract. Therefore, the terms of a contract of insurance law have to be strictly
construed and no exception can be made on the ground of equity.
Thus, it needs little emphasis that in construing the terms of a contract of insurance
important, and it is not open for the court to add, delete or substitute any words. It is also
well settled that since upon issuance of an insurance policy, the insurer undertakes to
indemnify the loss suffered by the insured on account of risk covered by the policy, its terms
have to be strictly construed to determine the extent of liability of the insurer. Therefore,
the endeavour of the court should always be to interpret the words in which the contract is
expressed by the parties.”
Under the circumstances, the Forum concurs with the decision of RI and the rejection of claim is
found to be in order. The Complaint is disallowed.
AWARD
Taking into account the facts & circumstances of the case and the personal submissions made
by both the parties and the information/documents placed on record, the rejection of claim is
found to be in order and in consonance with the terms and conditions of the policy and does
not require any interference at the hands of Ombudsman.
The Complaint is Disallowed.
Dated at Bengaluru on the 08
th
day of January, 2021
(NEERJA SHAH)
INSURANCE OMBUDSMAN
FOR THE STATE OF KARNATAKA
PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF KARNATAKA
(UNDER RULE NO: 17 of THE INSURANCE OMBUDSMAN RULES, 2017)
OMBUDSMAN- NEERJA SHAH
In the matter of: Mr. B A RAMAMURTHY V/s ROYAL SUNDARAM ALLIANCE INSURANCE CO LTD
Complaint No: BNG-H-038-2021-0419
Award No: IO/BNG/A/HI/0255/2020-21
1
Name & Address of the
Complainant
Mr. B A RAMAMURTHY
#43, II Cross, C R Layout, J P Nagar I Phase
BENGALURU – 560 078
Ph No 080-26530137
E-mail: NA
2
Policy No.
Type of Policy
Duration of Policy/Policy Period
MFH0004229000103
Family Health Floater Policy
02.07.2019 to 01.07.2020
3
Name of the Insured/ Proposer
Name of the policyholder
SBI Cards & Payment Services
Mr. B A Ramamurthy – Self
4
Name of the Respondent Insurer
Royal Sundaram Alliance Insurance Co Limited
5
Date of Repudiation
NA
6
Reason for repudiation/rejection
NA
7
Date of receipt of Annexure VI A
17.11.2020
8
Nature of complaint
Non-Issuance of Policy
9
Amount of claim
NA
10
Date of Partial Settlement
NA
11
Amount of relief sought
Renewal of Policy plus suitable monetary
compensation
12
Complaint registered under Rule no
13 (1) (f) of Insurance Ombudsman Rules, 2017
13
Date of hearing/place
13.01.2021 / Online VC
14
Representation at the hearing
a) For the Complainant
Self
Ms. Rashmi - Daughter
b) For the Respondent Insurer
Mr. Jaikumar T S, Manager
15
Complaint how disposed
Disallowed
16
Date of Award/Order
15.01.2021
17. Brief Facts of the Case
The complaint emanated due to non-issuance of policy by Respondent Insurer (RI). He
represented to Grievance Redressal Officer (GRO) of RI for renewal of policy, however his request
was not considered favourably. Hence, the Complainant approached this Forum for issuance of
policy.
18. Cause of complaint:
a. Complainant’s argument: Complainant alongwith wife and daughter were covered under
Group Family Health Floater policy issued by RI to customers of SBI Cards vide Master policy
reference no HS00000779000113. He is covered with RI since past 15+ years without any break.
The individual policies covering all 3 for present year were due for renewal on 01.07.2020.
Complainant was charged Rs 19,250/- as premium for insurance coverage for period 02.07.2019
to 01.07.2020. He submitted cheque for Rs 19,250/- to RI on 10.06.2020 based on previous
premium amount, which was encashed by RI on 23.07.2020. He submitted despite taking the
premium, policies have not been issued till date. Despite repeated reminders to RI for issuance of
policies on priority considering that he is a senior citizen and with entire world under the grip of
COVID-19, there was no response. Aggrieved by conduct of RI, he approached this Forum for
renewal of previous policy.
b. Insurer’s argument: The Respondent Insurer, in their Self Contained Note dated 30.12.2020
sent on e-mail dt 30.12.2020, submitted that complainant along with his wife and dependent
children was insured under Family Health Floater Policy since 02.07.2016, which has been
continuously renewed without break till 01.07.2020. However since the aforementioned product
was financially unviable, RI withdrew the product from market w.e.f. 01.04.2020. He was given an
option to migrate to alternate Group Health policy. Based on the revision, the premium payable
for new policies was Rs 35,644/- and same was informed to complainant vide mail dt 17.06.2020.
However, complainant had remitted an amount of Rs. 19,250/- based on premium amount of
previous year vide cheque dated 10.06.2020. The same was received by RI on 21.07.2020.
Thereafter he was requested to deposit additional amount of Rs 16,394/- for issuance of policies.
However complainant did not agree for the same and approached the Forum for issuance of
policies. Therefore, RI vide letter dated 27.11.2020 enclosing cheque for Rs. 19,250/- returned the
premium amount paid by him, which was not encashed by the complainant. Further, RI informed
that though the actual renewal premium for the migrated policies works out to Rs.61,496/-, but
since it had sent the renewal notices for Rs.35,644/-, complainant was requested to pay the
balance amount of Rs.16,394/- only as per original notice. RI also informed that it is ready to
extend the cover with all continuity of benefits once complete premium amount is received by
them.
19. Reason for Registration of complaint:
The complaint falls within the scope of the Insurance Ombudsman Rules, 2017 and so, it was
registered.
20. The following documents were placed for perusal:
d. Complaint along with enclosures,
e. SCN of the Respondent Insurer along with enclosures and
f. Consent of the Complainant in Annexure VI-A and Respondent Insurer in VII-A.
21. Result of the personal hearing with both the parties (Observations & Conclusions):
The dispute is with regard to non-renewal of an existing withdrawn product.
Personal hearing by the way of online Video-conferencing through Goto Meet was conducted in
the said case. Complainant along with his daughter & Representative of RI presented their case.
Confirmation from all the participants about the clarity of audio and video was taken and to which
the participants responded positively.
The Forum has perused the documentary evidence available on record and the submissions made
by both the parties.
Complainant submitted that existing policy was valid till 01.07.2020 and they had submitted
cheque for renewal of policies on 10.06.2020 to RI for amount of Rs 19,250/- based on the
previous year premium since there was no communication from RI. Same was credited to the
bank account of RI on 23.07.2020. He averred that despite taking the premium amount, RI did not
issue renewed policies till date. He also informed that complaint was registered with National
Human Rights Commission for the unnecessary harassment and mental agony undergone by them
for non-issuance of policies at a time when COVID-19 pandemic was prevalent in the world. His
daughter informed that RI has been continuously calling them for compromise settlement even
though the matter was sub-judice before this Forum. She also informed that RI cannot escape
from their responsibility merely be sending E-mail communications, when the preferred method
of communication is Indian Postal Services.
Representative of RI informed that since the product was withdrawn from market after approval
of the Regulator, the request of the complainant to renew existing policy as per previous year
policy premium rates was not possible as the same was financially unviable. However considering
the long-standing association with the customer, Representative of RI informed that they are
willing to provide coverage to customer subject to receipt of premium in full. The premium and
policy terms and conditions would be subject to new policy which has been approved by IRDAI,
but the complainant was not agreeable to the same. During the course of hearing he informed
that complainant has been provided with two options to opt in in lieu of withdrawn product –
Royal lifeline policy for which premium amount payable is Rs 61,496/- or the Group Health Policy
for which premium amount payable is Rs 35,644/-. He acknowledged that there was a deficiency
in service during the renewal of the policy, but objected to the argument of complainant
regarding allegations of harassment stating that RI is committed to customer satisfaction. He
submitted that COVID-19 pandemic has disrupted the service chain in year 2020 and it was
universal phenomenon that caused inconvenience to everyone.
Forum notes that Family Floater Health policy offered to complainant was a Customised Group
Product of RI which was specifically available for the customers of SBI Cards.
Complainant’s daughter contention was that it was mandatory on the part of RI to send Postal
hard copies of renewal letter, but no such communication was made by RI. Forum notes that
IRDAI circular IRDAI/CAD/CIR/PPHI/059/04/2019 dt 10.04.2019 has issued the following
guidelines:
“All insurers shall send all communication relating to issuance and servicing of insurance
policies such as proposal registration, further requirements for completing proposals and
various requirements of underwriting and/or relating pre-acceptance surveys etc, wherever
applicable in general insurance, information about policy issuance i.e acceptance /rejection
of proposals, renewal/lapse intimations/premium reminders wherever sent, bonus accrued
in life insurance participating policies, value of ULIP polices, and all other information that
has a bearing on servicing of insurance policy, either in the form of a letter, e-mail, sms or
any other electronic from approved by the Authority.”
Furthermore, renewal notice is a service gesture and insurance company is not obliged to give
notice for renewal as iterated in IRDAI circular no IRDAI/HLT/REG/CIR/152/06/2020 dt 11.06.2020.
Forum notes that RI has fulfilled this obligation much before the renewal date of the policy.
As regards to dispute over amount of premium payable under the Insurance policy, Forum notes
that Sub-regulation (e) of Regulation 10 of the IRDAI Health Regulations 2016 states:
“Subject to Regulation (3) (b), changes in rates will be applicable from the date of approval
by the Authority and shall be applied only prospectively thereafter for new policies and
from the date of renewal for the existing policies.”
As per IRDAI Guidelines on Product Filing in Health Insurance Business issued vide reference:
IRDA/HLT/REG/CIR/150/07/2016 dt 29.07.2016:
“Modification in terms and conditions of products under File and Use (Applicable to Life,
General and Health Insurers):
1. …
2. Any revision or modification of any approved health insurance product filed under File
& Use Procedure shall also require the prior clearance of the Authority as per the
guidelines issued from time to time.
3. An insurer, wishing to make changes to an existing product/rider or Addon, shall submit
an application to the Authority on modular basis furnishing information of the relevant
section of the File and Use application setting out the details of the changes or
modifications in the terms and conditions and/or price. Any such modification shall
have prior approval of the PMC as may be applicable. The PMC shall evaluate the
modification to examine whether it has any impact on pricing and record the same.
Accordingly, the product may be filed with the Authority for modification
4. …
5. …
6. …
7. In case any existing product offered by a General or Health Insurer is modified and
launched, the earlier version of the product shall automatically cease to exist for new
business and the modified version of the product shall be launched subject to complying
with Clauses (3), (5), (6) and (7) of Chapter – VI of norms on withdrawal of the products
specified under these Guidelines
Implementation of the modified rates, terms and conditions shall be allowed only at the
time of renewal of the Policy for the products offered by the general insurers and health
insurers.”
In the instant case, the Forum notes that policy plan under which complainant was covered for
the period 02.07.2019 to 01.07.2020 was withdrawn from 01.04.2020. Thus the existing policy
plan under which complainant was covered ceased to exist as on date of renewal and it bears the
approval of the Regulator.
Regulation 17(i) of the IRDAI Health Regulations 2016 (as amended vide notification dt
19.11.2019) state that RI is required to offer a suitable product for an existing customer
consequent upon withdrawal of an existing insurance product under which he/she is covered. The
Forum notes that the RI had given the two option to the complainant to choose an alternative
product available with them. But the complainant was not agreeable to premium and policy terms
and conditions under the new product. Thus contention of the complainant for alleged
harassment by RI in regards to policy servicing is not established.
However, the Forum also places on record the inept action of RI for encashing the premium
cheque and not issuing the policies or refunding the premium after approx. 5 months.
Under the circumstances, considering the age of complainant and benefits accrued under the
policy, the Forum advises the complainant to continue with the policy coverage from the two
available options provided by the RI by paying the additional amount. In case he decides
otherwise, the Forum directs RI to refund the amount collected as premium along with interest
@2% above bank rate from date of encashing the premium cheque till the date of initiation of
original refund i.e. 27.11.2020. The complaint for issuance of Insurance policy on basis of previous
year policy premium amount is disallowed.
AWARD
Taking into account the facts & circumstances of the case and the personal submissions made
by both the parties and the information/documents placed on record, the Forum advises the
complainant to continue with the policy coverage from the two available options provided by
the RI by paying the additional amount. In case he decides otherwise, the Forum directs RI to
refund the amount collected as premium along with interest @2% above bank rate from date of
encashing the premium cheque till the date of initiation of original refund i.e. 27.11.2020
The Complaint for issuance of Insurance policy on basis of previous year policy premium amount
is Disallowed.
Dated at Bengaluru on the 15
th
day of January, 2021
(NEERJA SHAH)
INSURANCE OMBUDSMAN
FOR THE STATE OF KARNATAKA
PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF KARNATAKA
(UNDER RULE NO: 17 of THE INSURANCE OMBUDSMAN RULES, 2017)
OMBUDSMAN – NEERJA SHAH
In the matter of Mr. MAYURA G N Vs HDFC ERGO GENERAL INSURANCE LIMITED
Complaint No: BNG-H-003-2021-0422
Award No.: IO/(BNG)/A/HI/0256/2020-21
1
Name & Address of the
Complainant
Mr. Mayura G N
B3-604, Kailash Block,
BDA Jnanabharathi Residential Enclave, Kengeri,
BENGALURU - 560059
Mobile # 9740084778
E-mail Id : [email protected]
2
Policy Number
Type of Policy
Duration of Policy/ Policy Period
2999201537516403000
Employer Provided GMC Policy
22.10.2019 to 21.10.2020
3
Name of the Insured/ Proposer
Name of the policyholder
Prysm Displays India Pvt Ltd
Mr. Mayura G N - Employee
4
Name of the Respondent Insurer
HDFC ERGO General Insurance Limited
5
Date of repudiation
NA
6
Reason for repudiation
NA
7
Date of receipt of Annexure VI-A
06.11.2020
8
Nature of complaint
Partial Settlement of COVID-19 claim
9
Amount of claim
₹. 20,773/-
10
Date of Partial Settlement
01.10.2020
11
Amount of relief sought
₹. 18,494/-
12
Complaint registered under Rule no:
13 (1) (b) of Insurance Ombudsman Rules, 2017
13
Date of hearing/place
13.01.2021 / Online VC
14
Representation at the hearing
a) For the Complainant
Self
b) For the Respondent Insurer
Mr Neeraj Shivangikar, AVP
15
Complaint how disposed
Disallowed
16
Date of Award/Order
15.01.2021
17. Brief Facts of the Case:
The complaint emanated from Partial settlement of claim towards hospitalization due to COVID -19 for
the period from 02.09.2020 to 07.09.2020. Despite representing to Grievance Redressal Officer (GRO)
of the Respondent Insurer (RI) for reconsideration of balance claim amount, but his plea was not
considered favourably. Hence the Complainant approached this Forum for settlement of his claim.
18. Cause of Complaint:
a) Complainant’s arguments:
The Complainant is covered under Employer provided GMC policy vide policy no
2999201537516403000 for a Sum Insured of ₹. 6,00,000/- from 22.10.2019 to 21.10.2020. He was
diagnosed as COVID-19 positive and hospitalised in Sparsh Hospital from 02.09.2020 to
07.09.2020. He submitted cashless claim request to RI vide claim no RC-HS20-11313421. For a bill
amount of Rs 1,21,342/-, the claim was settled for Rs 1,00,569/-. Rest expenses were disallowed
as non-medical expenses which was disputed by him. His representation to GRO for payment for
balance claim did not yield positive result. Hence he approached this Forum for resolution of
grievance.
b) Respondent Insurer’s Arguments:
RI in their Self Contained Note (SCN) dt 05.01.2021 submitted that Complainant (Insured Person –
hereafter referred to as IP) was insured with RI for SI of Rs. 6,00,000/-. IP was tested COVID-19
positive and was admitted at Sparsh Hospital from 02/09/2020 to 07/09/2020 for which claim
intimation was received by RI. After assessment of claim, it was settled for Rs. 1,11,439/- including
pre, post and main hospitalisation. Non-medical expenses of Rs 20,773/- were disallowed as per
the terms and conditions of the policy and guidelines issued by the IRDAI vide ref no
IRDA/HLT/REG/CIR/146/07/2016 dt 29.07.2016. The details of disallowed items are reproduced
below:
Bill No.
Service Type
Claimed
Amount
Deduction
Amount
Remarks – Not payable
items
086
Miscellaneous charges
880
880
Admission charges not
payable
86
Pharmacy Bill Head
6500
6500
Mask
86
Pharmacy Bill Head
1345
1345
Face Shield
86
Miscellaneous charges
660
660
Documentation charges
86
Pharmacy Bill Head
4035
4035
FACE SHIELD
86
Pharmacy Bill Head
210
210
Povidone
86
Pharmacy Bill Head
2000
2000
Gloves
86
Pharmacy Bill Head
60
60
COTTON BALS
86
Pharmacy Bill Head
99
99
GAUZE SWAB
86
Pharmacy Bill Head
1614
1614
Face Shield
86
Pharmacy Bill Head
310
310
DIGITAL THERMOMETER
86
Miscellaneous charges
3000
3000
Food Charges
86
Miscellaneous charges
60
60
Registration Charges not
payable
TOTAL
20773
20773
19. Reason for Registration of complaint:-
The complaint was registered as it falls within the scope of the Insurance Ombudsman Rules,
2017.
20. The following documents were placed for perusal.
a. Complaint along with enclosures,
b. Respondent Insurer’s SCN along with enclosures and
c. Consent of the Complainant in Annexure VIA & and Respondent Insurer in VII A.
21. Result of personal hearing with both the parties (Observations & Conclusions):
The dispute is with regard to short settlement of hospitalisation claim by RI.
Personal hearing by the way of online Video-conferencing through Goto Meet was conducted in
the said case. Mr Maurya G N (Complainant) and Mr. Neeraj (Representative of RI) presented their
case. Confirmation from all the participants about the clarity of audio and video was taken and to
which the participants responded positively.
This Forum has perused the documentary evidence available on record and the submissions made
by both the parties during the personal hearing.
Complainant has disputed the following deductions made under the claim:
1. Rs 15,494/- is deducted towards Masks, Gloves & Face Shield
2. Rs 3,000/- deducted towards Food.
The policy coverage clause is reproduced below:
“NOW THIS POLICY WITNESSETH that subject to the terms, conditions, exclusions and
definitions contained herein, or endorsed or otherwise expressed hereon, the Company
undertakes that if during the period stated in the Schedule, or during the continuance of
this policy by renewal, any INSURED PERSON shall contract any DISEASE or sustain any
INJURY and if such DISEASE or INJURY shall require any such INSURED PERSON, upon the
advice of a duly qualified MEDICAL PRACTITIONER to incur hospitalisation or DOMICILIARY
HOSPITALISATION EXPENSES for medical/surgical treatment at any HOSPITAL in India as an
inpatient, the Company will pay the amount of such expenses as would fall under different
heads mentioned below, and as are reasonably and necessarily incurred thereof by or on
behalf of such INSURED PERSON but not exceeding the sum insured for the person in any
one period of insurance as mentioned in the scheduled hereto.
a. Room, Boarding Expenses as provided by the HOSPITAL;
b. Nursing Expenses;
c. Surgeon, Anaesthetist, Medical Practitioner, Consultants, Specialist Fees;
d. Anaesthesia, Blood, Oxygen, Operation theatre Charges, Surgical Appliances,
Medicines and Drugs, Diagnostic Materials and X-Ray, Dialysis, Chemotherapy,
Radiotherapy, Cost of Pacemaker, artificial Limbs and similar expenses.”
Government of Karnataka vide notification no HFW 228 ACS2020 dt 23.06.2020 notified that
“in exercise of the powers conferred under the Disaster Management Act, 2005, the
undersigned in his capacity of chairman of the State Executive committee, under the
Powers vested under Section 24(f) and Section 24(l) of the Disaster Management Act, 2005,
issues the following orders to share the number of beds in private hospitals between
Government referred and Private patients and to regulate the package rates to be charged
by the PHPs for the treatment of Government referred COVlD-19 patients and the package
rate ceiling for treating Private COVID-19 patients
1. …
2. The following package rates inclusive of PPEs and other consumables shall apply for
the treatment of COVID Patients:
(a) …
(b) Package rate ceilings for private COVID-19 patients directly admitted by PHPs
making cash payment (non-insurance) shall be as follows
(1) General ward - Rs.10,000/-
(2) HDU - Rs.12,000/-
(3) Isolation ICU without ventilator - Rs.15,000/-
(4) Isolation ICU with ventilator Rs.25.000/-“
Thus Government of Karnataka has prescribed ceiling package rates to be charged by Hospitals for
treatment of COVID-19 positive patients. Though para 3 of the aforementioned notification states that
these rates are not applicable for patients subscribing to insurance packages, the Forum finds that they
represent the usual and customary charges as per policy definition:
“REASONABLE AND CUSTOMARY CHARGES means the charges for services or supplies,
which are the standard charges for the specific provider and consistent with the prevailing
charges in the geographical area for identical or similar services, taking into account the
nature of the illness / injury involved.”
Forum further finds that RI has taken the room category as ICU during the time of settlement.
Therefore per diem rate of Rs 15,000/- is payable to complainant as per aforementioned circular.
Thus the total package rate for hospitalisation of 5 days shall be Rs 75,000/- under reasonable and
customary charges.
Forum takes cognisance of the certificate dt 21.10.2020 issued by the Hospital stating that
separate billing for N-95 masks, face shield and encore Hand glove was required for the safety of
the staff. However the package rate given by Government of Karnataka is inclusive of all individual
itemised charges including but not limited to nursing charges, investigations including COVID-19
testing, food, drugs and consumables and PPE kits.
Since claim has already been settled for Rs 1,00,569/- towards the main hospitalisation bill under
cashless facility, the argument of the complainant that his claim has not been fully settled is not
established. The Forum notes that having settled an amount higher than the eligible amount, no
recovery of the same can be made by RI. In the interest of complainant, the Forum maintains the
status quo in regard to claim settlement. The complaint is disallowed.
A W A R D
Taking into account of the facts and circumstances of the case and the submissions made by both
the parties and documents submitted, the Forum maintains the status quo in respect of claim
settlement made by the RI.
The Complaint is Disallowed.
Dated at Bangalore on the 15
th
day of January, 2021
(NEERJA SHAH)
INSURANCE OMBUDSMAN
FOR THE STATE OF KARNATAKA
PROCEEDINGS BEFORETHE INSURANCE OMBUDSMAN, STATE OF KARNATAKA
(UNDER RULE NO: 16/17 of THE INSURANCE OMBUDSMAN RULES, 2017)
OMBUDSMAN – NEERJA SHAH
In the matter of MRS. JAGADAMBA Vs THE NATIONAL INSURANCE COMPANY LIMITED
Complaint No: BNG-H-048-2021-0425,0427,0429,0430,0431,0432,0433,0434,0435,
0438,0439,0440,0442,0444,0446,0449,0450
Award No.: IO/(BNG)/A/HI/0261 to 0277/2020-21
1
Name & Address of the Complainant
Mrs. Jagadamba
W/o Late Sri C K Parthasarathy, #70/2A
Prakruthi 6th Cross, Janatha Colony
Hulimavu, Bannerghatta Road
Bangalore, Karnataka – 560076
Mobile: 9986975481
Email: [email protected]
2
Policy Number
Type of Policy
Duration of Policy/ Policy Period
603901501810004113
Individual Mediclaim
01.02.2019 to 30.01.2020
3
Name of the Policyholder/Proposer
Name of the Insured
Mr. Parthasarthy C K
Mr. Parthasarthy C K
4
Name of the Insurer
The National Insurance Company Limited
5
Date of repudiation
20.02.2020 to 28.03.2020 (various dates listed in
the table of Observations and Conclusions)
6
Reason for repudiation
Insured underwent a day care procedure which
is beyond the scope of the policy.
7
Date of receipt of the Annexure VI-A
17.11.2020
8
Nature of complaint
Denial of health claim
9
Amount of claim
₹2,94,397/-
10
Date of Partial Settlement
NA
11
Amount of relief sought
₹2,94,397/-
12
Complaint registered under Rule no:
13 (1) (b) of Insurance Ombudsman Rules, 2017
13
Date of hearing/place
13.01.2021 / Online VC
14
Representation at the hearing
a) For the Complainant
Self
b) For the Respondent Insurer
Absent
15
Complaint how disposed
Disallowed
16
Date of Award/Order
19.01.2021
17. Brief Facts of the Case:-
The complaint emanated from repudiation of health claims (17 nos.) by the Respondent insurer
(hereafter referred to as RI). Complainant represented to Grievance Redressal Officer of RI to
reconsider the claim. However her plea was not considered favourably. Hence complainant
approached this Forum for resolution of her grievance.
18. Cause of Complaint:-
a) Complainant’s arguments:-
Complainant submitted that her husband Mr. Parthasarthy C K (Insured Person- hereby referred
as IP) was insured under policy no. 603901501810004113 for the period of 01.02.2019 to
31.01.2020. IP was a patient of multiple myeloma (plasma cell cancer in bone marrow), and he
was undergoing chemotherapy treatment at Fortis Hospital, Bannerghatta Road, Bangalore.
Reimbursement claims for all the medical bills were submitted to National Insurance Co. Ltd. and
United India Insurance Co. Ltd. All the 17 claims were rejected by the National Insurance Co. Ltd.
whereas other claims similar to these applied previously with United India Insurance were
reimbursed. Despite representing GRO of RI, the claims were not settled. Hence complainant
approached this Forum for resolution of her grievance.
b. Respondent Insurer’s Arguments:-
The Respondent Insurer submitted in their Self-Contained Note (SCN) vide letter dated 06.11.2020
that a mediclaim insurance policy was issued to Mr. Parthasarthy C K covering himself and his
spouse vide policy no: 603901501810004113 for the period of 01.02.2019 to 31.01.2020 with a
floater sum insured of ₹3,00,000/-. IP was a known case of multiple myeloma diagnosed in 2012,
status post autologous PBSCT in 2013, relapse in 2019. He has received four cycles of CyBorD
Chemotherapy. As he was in stringent CR, taken up for autologus PBSCT. Multiple relapses since
then and is on maintenance treatment for the same.
Final Diagnosis:
o Relapsed multiple myeloma
o Diagnosed with multiple myeloma in 2012,CYBORD 4 cycles
o Autologous PBSCT in 2013
o Relapse in 2015, 4 cycles of CYBORD
o Relapse in 2017,radiotherapy for plasmacytoma
o Relapse in 2019, started on KPD
Reason for the Repudiation:
The patient was admitted and discharged on the same day. Hence, 24 hours hospitalisation was
not completed.
As per the policy definition, hospitalisation is covered as follows:
"6.20 Hospitalisation means admission in a hospital for a minimum period of twenty four
consecutive hours except for specified procedures/treatments, where such admission could
be for a period of less than twenty four consecutive hours."
Additionally, the policy also covers Day Care treatment as follows:
"6.12 Day care procedure means medical treatment, and/or surgical procedure which is:
a) undertaken under General or Local Anaesthesia in a hospital/day care centre in less than
24 (twenty four) hrs because of technological advancement, and
b) which would have otherwise required a hospitalisation of more than 24 (twenty four)
hours.
Treatment normally taken on an out-patient basis is not included in the scope of this
definition."
As per the day care list attached with the policy, Chemotherapy is covered under Day Care.
However, as evident from the claim documents, Injection Carfilzomib was administered; whereas
the policy covers Parenteral Administration of Chemotherapeutic agents only. As Carfilzomib is a
Proteasome Inhibitor (Targeted/lmmuno Therapy) and is not a parenteral Chemotherapy drug.
Hence, it is not covered as a day care procedure.
19. Reason for Registration of complaint:-
The complaint falls within the scope of the Insurance Ombudsman Rules, 2017.
20. The following documents were placed for perusal:-
a. Complaint along with enclosures,
b. Respondent Insurer’s SCN along with enclosures and
c. Consent of the Complainant in Annexure VIA & and Respondent Insurer in VII A
21. Result of personal hearing with both the parties (Observations & Conclusions):-
The dispute is for non payment of health claim under the policy.
Personal hearing by the way of online Video-conferencing through GoTo Meet was conducted in
the said case. Complainant (Mrs. Jagadamba) joined and presented her case. RI could not connect
to the VC link. Confirmation about the clarity of audio and video was taken to which the
participants responded positively.
Complainant reiterated her earlier submissions. He submitted that the claim for the similar
treatment was previously settled by United India Insurance Co. Ltd.
This Forum has perused the documentary evidence available on record and the submissions made
by complainant during the personal hearing. The complainant was asked to produce the relevant
documentary proof of settlement made by the previous Insurer for the earlier claims. This Forum
did not receive any supporting documents by the complainant till the date of this order.
Forum notes that IP was diagnosed with multiple myeloma in year 2012 and was undergoing
scheduled Chemotherapy in Fortis Hospital, Bannerghatta Road, Bangalore.
Complainant preferred health reimbursement claim under the policy for the medical expenses
incurred. The claims were rejected by the RI as per the Clause 6.20 and 6.12 of the policy which
are reproduced as under:
6.20 Hospitalisation means admission in a hospital for a minimum period of twenty four
consecutive hours except for specified procedures/ treatments, where such admission
could be for a period of less than twenty four consecutive hours.
6.12 Day care treatment means medical treatment, and/or surgical procedure (as listed in
Annexure I) which is:
(i) undertaken under general or local anesthesia in a hospital/day care centre in less than
twenty four hrs because of technological advancement, and
(ii) which would have otherwise required a hospitalisation of more than twenty four hours.
Treatment normally taken on an out-patient basis is not included in the scope of this
definition.
Complainant has filed 17 claims, the details of which are given below:
Complaint Reg. No.
RI Claim No.
Date of Treatment
Date of Rejection
Claim Amount(₹)
BNG-H-048-2021-0425
MDI5366932
24-04-19
22-02-20
14381
BNG-H-048-2021-0427
MDI5366951
06-06-19
21-03-20
14776
BNG-H-048-2021-0429
MDI5366967
05-06-19
16-03-20
32767
BNG-H-048-2021-0430
MDI5365962
14-05-19
20-02-20
13747
BNG-H-048-2021-0431
MDI5367025
21-05-19
28-03-20
14429
BNG-H-048-2021-0432
MDI5367041
22-05-19
24-03-20
14983
BNG-H-048-2021-0433
MDI5367067
22-06-19
22-02-20
14865
BNG-H-048-2021-0434
MDI5366026
15-05-19
16-03-20
14099
BNG-H-048-2021-0435
MDI5365920
18-07-19
21-03-20
15644
BNG-H-048-2021-0438
MDI5366083
19-07-19
22-02-20
15206
BNG-H-048-2021-0439
MDI5366983
11-07-19
22-02-20
26173
BNG-H-048-2021-0440
MDI5366895
12-07-19
22-02-20
14144
BNG-H-048-2021-0442
MDI5367000
05-07-19
22-02-20
15394
BNG-H-048-2021-0444
MDI5366011
04-07-19
22-02-20
21426
BNG-H-048-2021-0446
MDI5366057
12-06-19
22-02-20
18636
BNG-H-048-2021-0449
MDI5366913
11-06-19
22-02-20
14775
BNG-H-048-2021-0450
MDI5366038
21-06-19
21-03-20
18952
Total Claim Amount
294397
Forum notes that in all the 17 cases the complainant was treated with injection Carfilzomib.
Forum finds from web search that Carfilzomib is a targeted therapy drug. It is prescribed along
with other cancer drugs but it is distinct from chemotherapy drug.
Forum note that targeted-therapy/immuno-therapy is not permissible day care treatment under
the policy.
Further, since administration of injection Carfilzomib does not involve any anaesthetic
administration, the said treatment is not covered under the definition of Day Cay Procedure as
per policy terms and conditions.
The Complainant submitted that her previous claims for similar treatment were allowed by United
India Insurance Company under a policy taken by her with that company. Forum notes that the
terms and conditions of one policy cannot be read into the terms and condition of another policy.
It is noted that the claims have been repudiated by the RI strictly in terms of the impugned policy.
In view of the above Forum does not find flaw with the decision of the RI in repudiating the claims
as per terms and conditions of policy. Hence the complaints are disallowed.
A W A R D
Taking into account of the facts and circumstances of the case and the submissions made by
both the parties and documents available on record, rejection of the claim by the Respondent
Insurer is found to be in order and in consonance with the terms and conditions of the policy
which does not require any interference in the hands of Ombudsman.
The Complaints are Disallowed.
Dated at Bangalore on the 19
th
day of January, 2021.
(NEERJA SHAH)
INSURANCE OMBUDSMAN
FOR THE STATE OF KARNATAKA
PROCEEDINGS BEFORETHE INSURANCE OMBUDSMAN, STATE OF KARNATAKA
(UNDER RULE NO: 16 of THE INSURANCE OMBUDSMAN RULES, 2017)
OMBUDSMAN –NEERJA SHAH
In the matter of: Mr. Jeevith Shetty Sowkoor Vs United India Insurance Company Limited
Complaint No: BNG-H-051-2021-0557
Award No.: IO/(BNG)/A/HI/0278/2020-21
● The Complaint emanated from the non settlement of health claim amount of Rs.4,69,063/-
vide claim number BLR-0520-PA-0002849 under the policy number
2405022819P106379826 issued by Respondent Insurer (RI) for a risk period from
19.08.2019 to 18.08.2020.
● Complainant was diagnosed with mitral valve prolapsed (mvp) symptomatic severe mr,
normal coronaries, good lv-functions. He was hospitalised at Aadarsh hospital, Udupi from
26.05.2020 to 26.05.2020.
● Cashless authorization for the above hospitalisation was rejected by RI. Post discharge
complainant filed for reimbursement claim which was rejected by RI on the ground of pre
existing disease (PED) waiting period under the policy.
● Complainant approached Grievance cell of RI vide mail dated 03.06.2020 requested to
consider the claim, but his plea was not considered favourably.
● Thereafter the complainant approached this forum vide letter dated 27.11.2020 for
settlement of claim. Complaint is posted for personal hearing on 03.02.2021
● After the intervention of this Forum, RI settled the claim as per term and conditions of the
policy.
● Complainant vide his mail dated 18.01.2021 addressed to this Forum confirmed the receipt
of claim amount and requested to withdraw the complaint.
● Since the complaint was resolved on compromise basis wherein both parties have agreed
for the same, the complaint is treated as Closed and Disposed off accordingly.
Dated at Bangalore on the 19
th
day of January, 2021
(NEERJA SHAH)
INSURANCE OMBUDSMAN
FOR THE STATE OF KARNATAKA
PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF KARNATAKA
(UNDER RULE NO: 17 of THE INSURANCE OMBUDSMAN RULES, 2017)
OMBUDSMAN- NEERJA SHAH
In the matter of: Mr. K SRISHAILAN V/s UNITED INDIA INSURANCE COMPANY LTD
Complaint No: BNG-H-051-2021-0499
Award No: IO/BNG/A/HI/0282/2020-21
1
Name & Address of the
Complainant
Mr. K Srishailan
Sriniketana, Near KVS Choultry, Keelukote
KOLAR – 563 101
Mobile # 9448586881
E-mail: [email protected]
2
Policy No.
Type of Policy
Duration of Policy/Policy Period
5001002819P112345074
IBA Policy – Corporation Bank
01.11.2019 to 31.10.2020
3
Name of the Insured/ Proposer
Name of the policyholder
Mrs. NCS Krupa Jyothsna - Wife
Corporation Bank
4
Name of the Respondent Insurer
United India Insurance Company Limited
5
Date of Repudiation
NA
6
Reason for repudiation/rejection
NA
7
Date of receipt of Annexure VI A
24.11.2020
8
Nature of complaint
Delay in settlement of claim
9
Amount of claim
₹. 13,300/-
10
Date of Partial Settlement
NA
11
Amount of relief sought
₹. 24,364/-
12
Complaint registered under Rule no
13 (1) (a) of Insurance Ombudsman Rules, 2017
13
Date of hearing/place
20.01.2021 / Online VC
14
Representation at the hearing
a)For the Complainant
Self
b)For the Respondent Insurer
Ms H A Pannaga, Dy manager
Dr. Sunil, TPA – Vipul MedCorp
15
Complaint how disposed
Partially Allowed
16
Date of Award/Order
21.01.2021
17. Brief Facts of the Case
The complaint emanated from delay in settlement of claim. Hence, the Complainant approached
this Forum for settlement of claims.
18. Cause of complaint:
a. Complainant’s argument:
Complainant along with his wife (Insured Person – hereafter referred as IP) was covered under the
Employer provided GMC policy issued by Respondent Insurer (RI) for the period 01.11.2019 to
31.10.2020. IP was diagnosed for mass – Dorsum of nose and underwent excision of the same
under General Anaesthesia on Out-patient basis on 02.11.2019 at Anugraha Health Care.
Reimbursement claim was submitted to RI. However inspite of reminders, the claim was not
settled.
b. Insurer’s argument:
The Respondent Insurer, in their Self Contained Note dated 06.01.2021 vide mail dt 06.01.2021,
submitted that based on the complaint received from this Forum, no details regarding intimation
of claim or submission of claim documents is available with RI or TPA (Vipul Medcorp).
19. Reason for Registration of complaint:
The complaint falls within the scope of the Insurance Ombudsman Rules, 2017 and so, it was
registered.
20. The following documents were placed for perusal:
g. Complaint along with enclosures,
h. SCN of the Respondent Insurer along with enclosures and
i. Consent of the Complainant in Annexure VI-A and Respondent Insurer in VII-A.
21. Result of the personal hearing with both the parties (Observations & Conclusions):
The dispute is regard to delay in settlement of claim. The Forum has perused the documentary
evidence available on record and the submissions made by both the parties.
Personal hearing by the way of online Video-conferencing through Goto Meet was conducted in
the said case. Complainant and Representatives of RI presented their case. Confirmation from all
the participants about the clarity of audio and video was taken and to which the participants
responded positively.
After registration of complaint in this Forum, it came to the notice of the Forum that no
representation was made to the RI. The representation e-mail submitted by complainant to this
Forum was sent to an invalid e-mail address, the delivery failure notification of which was never
brought to the notice of this Forum at the time of registration of the complaint or anytime
thereafter. However, in the interest of the complainant, the complaint was not disposed off.
Forum notes that IP was insured in IBA Policy with Vipul Medcorp recorded as the TPA. After
registration of complaint, RI informed that based on the complaint copy received from this Forum,
they were not able to trace the claim details. RI enquired with complainant to ascertain claim
document submission. Separate correspondence was made to complainant by this Forum.
Complainant informed this Forum that claim documents have been submitted to Mediassist India,
which is also a TPA of the RI. Same was forwarded to RI.
RI informed that complainant was advised to submit original documents to either one of it’s own
branch/office or in the office of the policy servicing TPA. However complainant has submitted
Xerox copies of few documents which did not contain the Discharge Summary and IP Break up Bill.
Hence they were unable to ascertain the admissibility of the claim. Query was made to RI to
ascertain admissibility of claim based on the documents submitted to this Forum, subject to
submission of original documents by the Insured.
During the course of hearing, representative of RI submitted that the claim has been repudiated.
Representative of RI was asked to submit the repudiation letter to this Forum and the
complainant. RI vide mail dt 20.01.2020, the claim was repudiated on the basis of scanned copy
received by them. RI requested the Forum to advise complainant to submit the original medical
documents to RI or policy servicing TPA (Vipul Medcorp) for them to pursue the same.
Since original claim documents have not been submitted by the complainant to RI or policy
servicing TPA i.e. Vipul Medcorp, the Forum advises the complainant to submit the same to RI for
processing.
Under the circumstances, the Forum cannot provide any relief to complaint without submission of
original documents. However it directs RI to ensure that claim is entertained on merits on receipt
of original documents subject to terms and conditions of the policy. The complaint is partially
allowed.
AWARD
Taking into account the facts & circumstances of the case and the personal submissions made
by both the parties and the information/documents placed on record, Forum finds no deficiency
in service of RI. Under the circumstances of the case, the Forum advises complainant to submit
the original documents to RI as per the laid down claim intimation criteria and directs RI to
consider the same on merits subject to terms and conditions of the policy.
The Complaint is Partially Allowed.
22. Compliance of Award:
The attention of the Complainant and the Insurer is hereby invited to the following:
a. The Complainant shall submit all requirements/Documents required for compliance of award
within 15 days of receipt of the award to the Respondent Insurer
b. As per Rule 17(6) of Insurance Ombudsman Rules, 2017, the insurer shall comply with the
award within thirty days of the receipt of the award and intimate compliance of the same to
the Ombudsman
Dated at Bengaluru on the 21
st
day of January, 2021
(NEERJA SHAH)
INSURANCE OMBUDSMAN
FOR THE STATE OF KARNATAKA
PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF KARNATAKA
(UNDER RULE NO: 17 of THE INSURANCE OMBUDSMAN RULES, 2017)
OMBUDSMAN- Smt.NEERJA SHAH
In the matter of SHRI PRAKASH GEORGE V/s MANIPAL CIGNA HEALTH INSURANCE COMPANY LIMITED(Mumbai)
Complaint No: BNG-H-053-2021-0485
Award No.: IO/(BNG)/A/HI/0286/2020-21
1
Name & Address of the Complainant
SHRI PRAKASH GEORGE ,
No.217, Kuteer Bliss Apartments,
Nobo Nagar, Bannerghatta Road,
Bangalore,
Karnataka-560 076
Mob.No. 08123890369
Mail ID : lissamma[email protected]m.
2
Policy No.
Type of Policy
Duration of Policy/ Policy Period
PROHLR340003518
Pro Health-Protect Family Floater Policy
05.09.2020 to 04.09.2021
3
Name of the Insured/ Proposer
Name of the policyholder
Smt.Lissamma Pa
SHRI PRAKASH GEORGE
4
Name of the Respondent Insurer
MANIPAL CIGNA HEALTH INSURANCE COMPANY
LIMITED(Mumbai)
5
Date of repudiation/rejection
09.10.2020
6
Reason for repudiation/rejection
Claim beyond the scope of policy coverage
7
Date of receipt of Annexure VI-A
06.11.2020
8
Nature of complaint
Rejection of claim under policy clause II.4
9
Amount of claim
13,920.00
10
Date of Partial Settlement
NA
11
Amount of relief sought
13,920.00
12
Complaint registered under Rule no:
13(1)(b)of Insurance Ombudsman Rules, 2017
13
Date of hearing/place
20.01.2021 / Bengaluru
14
Representation at the hearing
a) For the Complainant
Self
b) For the Insurer
Mrs.Swetha Nair-Assistant Manager,Legal
15
Complaint how disposed
Disallowed
16
Date of Award/Order
27.01.2021
17. Brief Facts of the Case:
The complaint emanated from the rejection of the claim on the ground of beyond the scope of
policy. Despite his taking up the matter with the GRO of Respondent Insurer (RI), his request was
not reconsidered. Hence he approached this Forum to get relief.
18. Cause of Complaint:
a. Complainant’s arguments: The Complainant submitted that he had taken Health Insurance
policy with the RI covering his family in the year 2016 and renewed there on. His spouse was
diagnosed with secondary hypothyroidism and she had under gone various tests as advised by the
doctor . He enquired with the customer care of the R.I about reimbursement of tests and the
same was assured by them. He took policy with the RI after verifying the websites of the RI
wherein they have advertised that the reimbursement of outpatient treatment and day care
facilities are allowed. Whereas, his claim reimbursement made towards various tests undergone
by his spouse was rejected by the R.I on the ground that OPD bills are not payable as per policy
clause II.4. His representation with the RI was not resolved favourably.
Hence, he approached this Forum for the relief.
b. Respondent Insurer’s Arguments:
The Respondent Insurer submitted their Self-Contained Note dated 18.01.2021 admitting the
insurance coverage. They submitted that the Complainant submitted proposal form bearing No.
PROHLR340003518 dated 6
th
July , 2017 for purchasing Health Insurance. The policy documents
along with a copy of the proposal form and the terms and conditions were duly delivered to the
Complainant’s registered address. The policy documents specifically states that policyholder
should check the enclosed policy documents carefully to make sure that all the details are correct.
However, the Insured did not notify the Company any discrepancy in the proposal form or in the
policy documents.
The Complainant on 30th September, 2020 registered a reimbursement claim bearing No.
22935129 for the reimbursement of expenses of Rs. 13,920/- incurred for the treatment taken at
Fortis Hospital from 10th August, 2020 to 15th August, 2020 due Hypothyroidism. On scrutiny of
the claim documents, it has been observed that the Complainant has availed only OPD treatment
and the bills submitted are all OPD bills Therefore, the claim was found to be not admissible as
policy covers only in- patient hospitalization of at least 24 hours or day care treatments as defined
in the policy. Accordingly the Company rejected the claim through rejection letter dated 9th
October, 2020.
It is submitted that Insurance is a contract between the insured and the insurer and the terms and
conditions of the Policy of Insurance are strictly binding upon the parties.
Relying on the decision of the Hon’ble Supreme Court in the case of Export Credit Guarantee
Corporation Of India Ltd. v. Garg Sons International (2013 (1) Scale 410), Suraj Mal Ram Niwas
Oil Mills (P) Ltd. Vs. United India Insurance Co. Ltd. [(2010) 10 SCC 567] and General Assurance
Society Limited vs.Chandumull Jain & Anr., (1966) 3 SCR 500 they requested the Forum to
absolve them from the complaint.
19. Reason for Registration of complaint:-
The complaint falls within the scope of the Insurance Ombudsman Rules, 2017.
20. The following documents were placed for perusal.
d. Complaint along with enclosures,
e. Respondent Insurer’s SCN along with enclosures and
f. Consent of the Complainant in Annexure VI-A & and Respondent Insurer in VII-A
21. Result of personal hearing with both the parties (Observations & Conclusions):
Personal hearing was conducted through video conference and the participants confirmed the
clarity of audio and video.
This Forum has perused the documentary evidence available on record. The issue to be decided is
whether rejection of the claim on the ground of OPD treatment beyond the scope of policy
coverage is in order.
The Complainant and RI reiterated their contentions. The complainant strongly contended that
the advertisement in the website of the RI states that treatment taken under OPD are reimbursed
by the Insurance company. Hence he took the policy from the R.I. The Forum asked the
complainant whether the Insured Person was hospitalized for the treatment for which he replied
in negative. R.I submitted that as per policy terms the complainant is eligible for reimbursement
of Rs.500/- only towards OPD charges which has been already paid to him and the complainant
did raise any objection.
The policy defines Basic Cover under clause II and II.1 for Inpatient Hospitalization which are
reproduced as under.
‘cover Medical Expenses of an Insured Person in case of Medically Necessary Hospitalization
arising from a Disease/ Illness or Injury provided such Medically Necessary Hospitalization is for
more than 24 consecutive hours provided that the admission date of the Hospitalisation due to
Illness or Injury is within the Policy Year.
The R.I rejected the claim under policy Clause II.4. - Day Care Treatment which is reproduced as
under:
‘cover payment of Medical Expenses of an Insured Person in case of Medically Necessary Day Care
Treatment or Surgery that requires less than 24 hours Hospitalization due to advancement in
technology and which is undertaken in a Hospital / nursing home/Day-care Centre on the
recommendation of a Medical Practitioner. Any treatment in an outpatient department/OPD is not
covered ‘.
The Forum observes that the bills produced for reimbursement clearly show that the treatment
taken was on ’ Outpatient’ basis on different dates from 10
th
August 2020 to 23
rd
September
2020 . The supporting Doctor’s certificate dt.12.10.2020 of Fortis Centre for Diabetes and
Endocrinology shows that the IP consulted for follow up for the treatment for
Hypothyroidism(Secondary) for which she had to undergo MRI-Brain and various other hormonal
tests as prescribed by him on 16.09.2020. The Forum notes that the IP was neither hospitalized
nor took treatment under Day-care.
In view of the above Forum does not find flaw with the decision of R.I in restricting the claim.
This Forum also relies on decision of the Hon’ble Supreme Court of India in the matter of Export
Credit Guarantee Corp of India Ltd. Vs Ms.Garg Sons International held that “the insured cannot
claim anything more than what is covered by the insurance policy.”…the terms of the contract
have to be construed strictly, without altering the nature of the contract as the same may affect
the interests of the parties adversely.”
Hence the complaint is DISALLOWED.
A W A R D
Taking into account of the facts and circumstances of the case, the documents and the
oral submissions made by both the parties, this Forum does not find any flaw with the
decision of the Respondent Insurer in restricting the claim in accordance with the
terms and conditions of policy.
Hence the complaint is DISALLOWED.
Dated at Bangalore on the 27
th
day of JANUARY , 2021
(NEERJA SHAH)
INSURANCE OMBUDSMAN
FOR THE STATE OF KARNATAKA
PROCEEDINGS BEFORETHE INSURANCE OMBUDSMAN, STATE OF KARNATAKA
(UNDER RULE NO: 16/17 of THE INSURANCE OMBUDSMAN RULES, 2017)
OMBUDSMAN – NEERJA SHAH
In the matter of MRS. NAYANA SHETTY K Vs UNITED INDIA INSURANCE COMPANY LIMITED
Complaint No: BNG-H-051-2021-0448
Award No.: IO/(BNG)/A/HI/0287/2020-21
1
Name & Address of the Complainant
Mrs. Nayana Shetty K
E No 210808, Union Bank of India
Credit Risk Management Department
Head Office Pandeshwar,
Mangalore, Karnataka - 575001
Mobile no: 9448626501
Email ID: [email protected]om
2
Policy Number
Type of Policy
Duration of Policy/ Policy Period
5001002818P109891131
Group Mediclaim
01.10.2018 to 30.09.2019
3
Name of the Policyholder/Proposer
Name of the Insured
IBA (A/c: Corporation Bank)
Mrs. Nayana Shetty K
4
Name of the Insurer
United India Insurance Company Limited
5
Date of repudiation
NA
6
Reason for repudiation
NA
7
Date of receipt of the Annexure VI A
13.11.2020
8
Nature of complaint
Short Settlement of health claim
9
Amount of claim
Claim 1:- Rs.58,857/- and Claim 2:- Rs.1,475/-
10
Date of Partial Settlement
05.10.2019
11
Amount of relief sought
Rs.18,017/- [16542 + 1475]
12
Complaint registered under Rule no.
13 (1) (b) of Insurance Ombudsman Rules, 2017
13
Date of hearing through Online VC
20.01.2021
14
Representation at the hearing
a) For the Complainant
Self
b) For the Respondent Insurer
Srijani – Assistant Manager
Dr. Komal Sindhe
15
Complaint how disposed
Allowed
16
Date of Award/Order
27.01.2021
17. Brief Facts of the Case:
The complaint emanated from short settlement of health claim by Respondent insurer (hereafter
referred to as RI). Complainant represented to Grievance Redressal Officer (GRO) of RI for
reconsideration of her claim. However her plea was not considered favourably. Hence the
complainant approached this Forum for resolution of her grievance.
18. Cause of Complaint:
a) Complainant’s arguments:
The Complainant (Insured Person - IP) submitted that she was covered under a group health
insurance policy with RI vide policy no. 5001002818P109891131 with a sum insured of
Rs.3,00,000/- and a corporate buffer utilisation amount of Rs.1,00,000/- for the risk period from
01.10.2018 to 30.09.2019. IP was diagnosed with Aplastic Anaemia and she was admitted at
Father Muler Medical College Hospital, Mangaluru from 16.11.2018 to 23.11.2018. IP incurred an
expense of Rs.3,58,857/- and RI approved the claim of Rs.3,00,000/- and remaining Rs.58,857 was
claimed under the corporate buffer utilisation. Claim was further settled for Rs.42,315/- only. IP
represented to the GRO of RI for settling the balance amount of Rs.16,542/-. IP also incurred an
expense of Rs. 215 and Rs.1260/- in the month of July 2019 and Sep 2019 and claim for it under
the corporate bufer which also was not paid by RI to the IP. IP did not get any favourable
response. Hence, she approached this Forum for help in getting her eligible amount from RI.
b. Respondent Insurer’s Arguments:
The RI submitted in their Self Contained Note (SCN) vide email dated 19.01.2021 that a group
mediclaim policy has been issued to Corporation Bank employees vide policy
no. 5001002818P109891131 for a risk period 01-Oct-2018 to 30-Sep-2019. IP is included in the list
of insured persons under the family floater sum insured of Rs.3,00,000/-. This complaint is
pertaining to claim number CCN:19973266 and CCN:20348407. IP was admitted at Father Muller
Medical College Hospital, Mangaluru from 16.11.2018 to 23.11.2018. She is a known case of
Aplastic Anaemia and taking Tablet Revolade on a regular basis. IP submitted post hospitalization
claim of Rs.63082/-. Rs.4225/- was settled vide claim number CCN:19973266 and deducted the
remaining Rs.58857/- due to sum insured exhaust. Later, on receipt of the corporate buffer
approval, another claim was generated vide claim number CCN:20348407 and claim amounting to
Rs.42315/- was settled out of the remaining balance amount. While settling the claim, bills which
fall beyond the 90 days of hospitalization was not considered as per the policy terms and
conditions. The calculation is as under:
Post hospitalization limit (90 days after the discharge date) : 20/02/2019
Bill Date
Bill Amount
Paid
Not Paid
06/02/2019
Med
165.4
165.4
0
06/02/2019
Med
15700
15700
0
10/02/2019
Lab
265
0
265
13/02/2019
Med
222
222
0
13/02/2019
Med
339
339
0
14/02/2019
Med
14140
14140
0
20/02/2019
Med
274.3
274.3
0
20/02/2019
Med
15700
15700
0
27/02/2019
Med
261.9
0
261.9
27/02/2019
Med
15500
0
15500
28/02/2019
Lab
515
0
515
63082.6
46540.7
16541.9
Payment details
Claim id
Paid in INR
19973266
4225
20348407
42315
Total Paid
46540
While reviewing the claim, it is found that the bill dated 10.02.2019 amounting to Rs.265/- was
wrongly deducted and the same will be processed. The claim has been processed as per policy
terms and conditions. Clause 2.38 of the policy reads as under:
POST HOSPITALISATION MEDICAL EXPENSES
Relevant medical expenses incurred immediately 90 days after the Insured person is
discharged from the hospital provided that;
a. Such Medical expenses are incurred for the same condition for which the Insured
Person’s Hospitalisation was required; and
b. The In-patient Hospitalisation claim for such Hospitalisation is admissible by us.
Regarding the corporate buffer, Total Corporate Buffer of Rs.100 crores is allocated in the policy in
proportion to the total premium of all Banks to the individual premium of each bank. Final
adjustment of corporate buffer shall be done at the end of the policy depending upon the
deletions and additions made. Even though an implied condition it is declared that the corporate
buffer payments shall be subject to terms and conditions of the policy.
In view of their submissions, the RI prayed for passing an appropriate order.
19. Reason for Registration of complaint:-
The complaint falls within the scope of the Insurance Ombudsman Rules, 2017.
20. The following documents were placed for perusal.
a. Complaint along with enclosures,
b. Respondent Insurer’s SCN along with enclosures and
c. Consent of the Complainant in Annexure VIA & and Respondent Insurer in VII A
21. Result of personal hearing with both the parties (Observations & Conclusions):
The dispute is whether the settlement of health claim under the policy is in order or not.
Personal hearing by the way of online Video-conferencing through GoTo Meet was conducted in
the said case. Complainant and Representative of RI joined using online VC and presented their
case. Confirmation from all the participants about the clarity of audio and video was taken to
which the participants responded positively. Complainant and Representative of RI reiterated
their earlier submissions.
Forum has perused the documentary evidence available on record and the submissions made by
both the parties during the personal hearing.
IP is a known case of Aplastic Anaemia and is regularly taking tablet Revolade as per the
prescription of the treating doctor.
It is noted that IP has got the sum insured of Rs.3,00,000/- and has exhausted the sum insured.
The policy has a Corporate Buffer which reads as follows:
Corporate Buffer
Corporate Buffer of Rs.100 crores is
incorporated in the policy in co-relation to the
Initial Premium of Rs. 416 Crores (for first year
i.e 2015-16), envisaged to be paid at the
commencement of the employees group health
insurance policy collectively by the various
member Banks, of the Indian Banks’ Association.
This Figure of Rs. 100 Crores Corporate Buffer
would be in correlation to the total premium
received by the Insurance Company this year.
Corporate Buffer Allotted : Rs. 02,43,80,000/-
Since the IP has exhausted the sum insured, she applied to the Deputy General Manager, Human
Resource Management Division, Corporation Bank, Head Office, Mangalore, who under the
prescribed procedure permitted her withdrawal of Rs.58,857/- from the Corporate Buffer.
Forum notes that under policy terms and conditions, it is nowhere mentioned that Corporate
Buffer is subject to the said policy terms and conditions. In this situation no word can be
read/implied in the policy which is not in the policy.
Hence the repudiation of the claim by limiting the amount of Corporate Buffer to Rs.42,315/- is
not in order. Forum further find that IP has filed one more claim of Rs.1,475/- pertaining to the
same treatment for which she is eligible.
Accordingly Forum directs RI to settle the balance amount of Rs.16,542/- pertaining to first claim
and for the second claim IP is directed to obtain the required authorisation for utilising the
Corporate Buffer amount from her Corporate/Employer and submit it to RI for claiming the
amount of Rs.1,475/-. The complaint is allowed.
A W A R D
Taking into account of the facts and circumstances of the case and the submissions made by
both the parties and documents submitted during the course of the Personal Hearing, the
Respondent Insurer is directed to settle the balance claim of Rs.16,542/- after collecting all
the relevant documents as per terms and conditions of the policy along with interest from
the date of submission of the last relevant document by the Insured till the date of payment
of the claim as per Regulation 16.1.(ii) of IRDAI’s Protection of Policyholders’ Interests
Regulations, 2017.
The Complaint is ALLOWED.
22. Compliance of Award:
Attention of the Complainant and the Insurer is hereby invited to the following:
a) The Complainant shall submit all requirements/Documents required for settlement of award
within 15 days of receipt of the award to the Respondent Insurer.
b) According to Rule 17(6) of the Insurance Ombudsman Rules, 2017, the insurer shall comply
with the award within thirty days of the receipt of the award and intimate compliance of the
same to the Ombudsman.
Dated at Bangalore on the 27
st
day of January, 2021.
(NEERJA SHAH)
INSURANCE OMBUDSMAN
FOR THE STATE OF KARNATAKA
PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF KARNATAKA
(UNDER RULE NO: 17 of THE INSURANCE OMBUDSMAN RULES, 2017)
OMBUDSMAN – Smt. NEERJA SHAH
In the matter of Shri. SANDEEP KUMAR PATEL V/s UNITED INDIA INSURANCE COMPANY LIMITED
Complaint No: BNG-H-051-2021-0476
Award No. : IO/(BNG)/A/HI/0288/2020-21
1
Name & Address of the Complainant
Mr. G.Sandeep Kumar Patel,
E-215189, Senior Manager,
Union Bank ,KYC & AML Central Office,
Mangalore,
Karnataka 570 001.
Mob.No. 09792570871
E-mail : sandeeppatel@unionbankofindia.com
2
Policy No.
Type of Policy
Duration of Policy/ Policy Period
5001002818P109891131
Group Health Policy
01.10.2018 to 30.09.2019
3
Name of the Insured/ Proposer
Name of the policyholder
Smt.Chitra Rekha Patel
Mr. G.Sandeep Kumar Patel,
4
Name of the Insurer
United India Insurance Company Limited
5
Date of repudiation
03.07.2019
6
Reason for repudiation
Hospitalization is primarily for diagnostic
evaluation.
7
Date of receipt of Annexure VI-A
13.11.2020
8
Nature of complaint
Rejection of claim
9
Amount of claim
₹.23,309/-
10
Date of Partial Settlement
NA
11
Amount of relief sought
₹.23,309/-
12
Complaint registered under Rule no:
13 (1)(b) of Insurance Ombudsman Rules, 2017
13
Date of hearing/place
20.01.2021 / Bengaluru
14
Representation at the hearing
a) For the Complainant
Self
b) For the Respondent Insurer
Smt.Srijani- Assistant Manager
15
Complaint how disposed
Allowed
16
Date of Award/Order
27.01. 2021
17. Brief Facts of the Case:
The complaint emanated from the rejection of cost claim on the ground that hospitalization of IP
was only for diagnosis and evaluation purpose. Despite taking up the matter with the Respondent
Insurer (RI), the same was not considered favourably. Hence he approached the Forum for relief.
18. Cause of Complaint:
a) Complainant’s arguments:
The Complainant submitted that his mother who is 70 years old was admitted to the hospital on
07.05.2019 as she was unable to stand and walk normally due to abnormal breathing problem .
During the hospitalization she has undergone several tests as per advice by the Doctor and was
diagnosed with Hyponatremia . He submitted claim to the R.I for reimbursement of medical
expenses. The R.I rejected the claim stating that hospitalization was primarily for diagnostic
evaluations and treatments that can be managed on outpatient basis.
His representation to GRO of RI was not considered favourably. Hence he approached Forum for
relief.
b) Respondent Insurer’s Arguments:
The Respondent Insurer submitted their Self-Contained Note dated 18.01.2021 admitting the
coverage of IP under the policy and rejection of claim on the ground of Clause 4.7 of policy terms
and conditions.
The complainant applied for medical reimbursement of Rs.23,309/- for the hospitalization of IP
in A.J. Hospital & Research Centre on 7
th
May 2019 at 2.30 PM and discharged on 8
th
May 2019
with a c/o breathing difficulty since 3 months with C/o bilateral pedal oedema. O/E-P=98/min, BP-
120-70 mmHg, RR-20/min, SPO2-98% on room air, Te,p-Afeb. On admission she was treated with
Inj.Pan, Inj.Emset with antihypertensive with anti-depressant Tab.Eliwel 10 mg. and underwent
investigations such as blood with X-Ray with Echo. She was diagnosed with Hypertension,
Hyponatraemia treated symptomatically and discharged in stable condition. This shows that she
was hospitalized primarily for evaluation and treated with oral medicines. Accordingly the claim
was rejected as per policy Terms & Conditions.
Hence, RI has requested to absolve them from the complaint made.
19. Reason for Registration of complaint:-
The complaint falls within the scope of the Insurance Ombudsman Rules, 2017
20. The following documents were placed for perusal.
a. Complaint along with enclosures,
b. Respondent Insurer’s SCN along with enclosures and
c. Consent of the Complainant in Annexure VIA & and Respondent Insurer in VII A
21. Result of personal hearing with both the parties (Observations & Conclusions):
The hearing was conducted through video conference. The participants confirmed clarity of audio
and video.
The issues which require consideration is the rejection of claim on the ground of hospitalization
was for diagnosis & evaluation is in order.
Both the parties reiterated their contentions. The Complainant strongly contended that the IP
being old age fell down and was unconscious. Hence there was need for hospitalization as
suggested by the treating doctor. R.I strongly contended that the IP was diagnosed with
Hyponatraemia and there is no active line of treatment. The medicines prescribed are only
Calcium, Anti-depression and Hypertension.
The Forum perused the documentary evidence available on records and the submissions made by
both the parties during the personal hearing.
The Policy Condition 4 deals with Exclusions as under:
‘The Company shall not be liable to make any payment under this policy in respect of any expenses
whatsoever incurred by any Insured Person in connection with or in respect of’:
The relevant policy sub-condition No.4.7 on which the claim was rejected is reproduced as under:
‘charges incurred at Hospital or Nursing Home primarily for diagnosis X-ray or Laboratory
examinations or other diagnostic studies not consistent with or incidental to the diagnosis and
treatment of positive existence of presence of any ailment, sickness or injury , for which
confinement is required at a Hospital/Nursing Home, unless recommended by the attending
doctor’.
The Discharge Summary of A.J.Hospital & Researach Centre shows that the IP aged about 70 years
was admitted on 07.05.2019 at 14.03 hrs and discharge on 08.05.2019 . She was diagnosed with
Hypertension & Hyponatremia. The Chief complaints shows that she had breathing difficulty from
past 3 months and complaints of bilateral pedal edema, admitted for further management.
Investigations are done as per the Doctor’s daily progress notes advice for necessitating the
treatment during her hospitalization. She was treated conservatively and establishes that her
hospitalization was medically necessitated.
In view of the above ,Forum finds that the rejection of claim on the ground of hospitalization was
for diagnosis and evaluation is not in order and does not concur with the decision of the RI in
restricting the claim and directs the R.I to settle the claim as per terms and conditions of the
policy.
Hence, the complaint is ALLOWED.
A W A R D
Taking into account of the facts and circumstances of the case, the documents the oral
submissions made by the RI, this Forum is of the opinion that the decision of the Respondent
Insurer in restricting the claim as above is not in accordance with the terms and conditions of
policy and not found to be in order.
This Forum directs the Respondent Insurer to settle the claim as above as per the terms and
conditions of policy along with interest @ 6.25% + 2% from the date of receipt of last
necessary documents to the date of payment of claim, as per regulation 16 (1) (ii) of
Protection of Policy Holders’ Interests Regulations, 2017 issued vide notification dated
22.06.2017.
Hence, the complaint is ALLOWED.
22. Compliance of Award:
Attention of the Complainant and the Insurer is hereby invited to the following:
a. The Complainant shall submit all requirements/Documents required for settlement of
award within 15 days of receipt of the award to the Respondent Insurer.
b. According to Rule 17(6) of the Insurance Ombudsman Rules, 2017, the insurer shall
comply with the award within thirty days of the receipt of the award and intimate
compliance of the same to the Ombudsman.
Dated at Bengaluru on the 27
th
day of JANUARY 2021.
(NEERJA SHAH)
INSURANCE OMBUDSMAN
FOR THE STATE OF KARNATAKA
PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF KARNATAKA
(UNDER RULE NO: 17 of THE INSURANCE OMBUDSMAN RULES, 2017)
OMBUDSMAN – Smt.NEERJA SHAH
In the matter of Smt.KAVYA SRINIVASAMURTHY V/s BAJAJ ALLIANZ INSURANCE CO. LTD.(PUNE)
Complaint No: BNG-H-005-2021-0516
Award No.: IO/(BNG)/A/HI/0289/2020-21
1
Name & Address of the Complainant
Smt.Kavya Srinivasa Murthy,
601, 4
th
Stage, 3
rd
Phase,
Vijayanagar, Mysore,
KARNATAKA -570017
Mob.No. 098844840309
Mail ID : kavya.srin[email protected]om
2
Policy No.
Type of Policy
Duration of Policy/ Policy Period
04-20-1919-8403-00000197
Group Medical Insurance Program
01.09.2019 to 31.08.2020
3
Name of the Insured/ Proposer
Name of the policyholder
Smt. Kavya Srinivasa Murthy
Self
4
Name of the Respondent Insurer
BAJAJ ALLIANZ INSURANCE CO. LTD.(PUNE)
5
Date of repudiation
25.02.2020
6
Reason for repudiation
Ayurvedic treatment- there was no active line of
treatment being administered.
7
Date of receipt of Annexure VI-A
25.11.2020
8
Nature of complaint
Rejection of claim
9
Amount of claim
₹.47000/-
10
Date of Partial Settlement
NA
11
Amount of relief sought
₹.47000/-
12
Complaint registered under Rule no:
13 (1) (b) of Insurance Ombudsman Rules, 2017
13
Date of hearing/place
20.01.2021 / Bengaluru
14
Representation at the hearing
a) For the Complainant
Absent
b) For the Respondent Insurer
Smt.Smeeitaa Salve- Assistant Manager-Legal
Dr.Ravindr TPA & Legal
15
Complaint how disposed
Partially Allowed
16
Date of Award/Order
28.01.2021
17. Brief Facts of the Case: It is a case of rejection of ayurvedic treatment claim as per terms and
conditions of policy. The Complainant took up the matter with the Grievance Cell of the
Respondent Insurer (RI) and the same was not considered favourably.
18. Cause of Complaint:
a) Complainant’s arguments: The Complainant submitted that she opted for alternate medical
treatment at SKS Ayurvedic Medical College to avoid surgery due to younger age . The RI applied
medical protocol of allopathic while processing her claim for Janusanghigata Vata diagnosed by
Ayurvedic Hospital. After preliminary examination the treating Ayurvedic Doctor advised her to
get admitted for better treatment and results for her Ligament Injury( Abhigat). Her treatment
falls and qualifies under the 20 disease guidelines being the out come of proper consultation
issued by Government of India, Ministry of Ayush, New Delhi. Her representation with the RI was
not considered favourably. Hence she approached the forum for relief.
b) Respondent Insurer’s Arguments:
RI submitted their Self Contained Note vide mail dt. 06.12.2020 admitting the policy coverage and
rejection of claim as per policy terms and conditions.
There is no deficiency of service or unfair trade practice on the part of the Insurance Company.
Hence the Complaint is liable to be dismissed at the outset for want of cause of action. Insurance
Policy is a contract and both the parties are under obligation to obey/fulfil all the terms and
conditions of the same in the strict sense of the words written therein. As the terms and
conditions of the Policy are sacrosanct, the claim arrived is also processed within the precincts of
the Policy only.
The complainant was hospitalised in SRI ADICHUNCHANAGIRI SHIKAHANA TRUST – BANGALORE –
KARNATAKA from 24-Dec-2019 to 08-Jan-2020 with complaint of both knee joint pain since 3 years
and diagnosed as Janu Sandhigata Vata (Osteoarthritis of the knee joint) and underwent below
Ayurvedic therapies and oral medication like churna and tablets-
Sarvanga Abhyanga-Sarvanga Abhyanga is a process in which massage is done to the whole
body Warm oils deeply penetrate into the cells and release physical, mental and spiritual toxins,
hence sarvanga abhyanga works as detoxifying as well as healing cellular therapy. (40 mins
time)
Stanika Lepa - plain medicated paste is applied over particular part of the body. This treatment
can be used in reducing local pain, swelling and discoloration. It also helps in sprains and
fractures. It can also be used in improving complexion, to tighten the skin and removes
wrinkles.
Mostly Ayurvedic therapies are for relaxation, rejuvenation of whole body but therapies like
Vaman, Virechana in Panchkarma needs hospitalisation due to uncertainty of complications. But
in this case no any Ayurvedic karma is performed or any investigation reports shows adverse
finding suggesting treatment and which requires need for hospitalisation.
On scrutiny of documents it is evident that insured is having long standing ailment of knee pain
and as discharge summary suggest patient clinical condition is vitally stable and still admitted
without any radiological examination of knee. Ayurvedic therapies administered without assessing
pathology involved in knee and given therapies are palliative and not curative, so it is case of rest
and cure and can be treated with oral medication on OPD basis. There is no such active line of
treatment being administered or any such investigative procedure being performed which
support the need of hospitalization. Therapies which are performed for 40 mins and with oral
medication without any side effects doesn’t warrant hospitalisation, hence the claim is repudiated
as per relevant exclusion C-10 of policy terms and conditions as under :
‘Charges incurred at Hospital or Nursing Home primarily for diagnostic, X-ray or laboratory
examinations not consistent with Or incidental to the diagnosis and treatment of the positive
existence or presence of any ailment, sickness or injury, for which confinement is required at a
Hospital/Nursing Home’.
However without prejudice to defense and without admitting liability , the claim payable will not
be more than Rs.39,895/- as per terms and conditions of the policy.
They claimed to reserve their right of amendment of the present Written Version on revelation of
new facts and circumstances for facilitating justice in the present case.
In view of the above the R.I requested the Forum to absolve them from the complaint.
19. Reason for Registration of complaint:-
The complaint falls within the scope of the Insurance Ombudsman Rules, 2017
20. The following documents were placed for perusal.
d. Complaint along with enclosures,
e. Respondent Insurer’s SCN along with enclosures and
f. Consent of the Complainant in Annexure VIA & and Respondent Insurer in VII A
21. Result of personal hearing with both the parties (Observations & Conclusions):
Personal hearing was conducted through video conference and the complainant did not appear
for the personal hearing. And all other participants confirmed the clarity of audio and video.
The issue which require consideration is whether the rejection of claim for the Ayurvedic
treatment undergone by the complainant on the ground that there was no active line of
treatment given are in order.
This Forum has perused the documentary evidence available on record and the submissions made
by the R.I during the personal hearing. The RI reiterated their contentions earlier made. The RI
was asked to provide bifurcation for Rs. 39,895/- as mentioned in their SCN. They submitted the
same after the hearing.
The Discharge Summary of Sri Kalabyraveswara Swamy Ayurvedic medical College hospital and
Research Centre for the period 24.12.2019 to 08.01.2020 show that the complainant was
diagnosed with ligament tear ,C/o pain in both Knee joint associated with burning sensation all
over the body. The treatment given during the hospitalization shows as ‘Manjisthadi Lepa,
Muriveena taila, Sarvanga Abhyanga, Sarvanga Shastika Shalipinda Sweda’ and the oral medicines.
During the hospitalization the complainant was advised by the treating doctor on 30.12.2019 to
undergo investigation for RA, CRP,HB,TC,DC,ESR to support the treatment.
This Forum notes the Circular No.T-1 2016/13/2008-DCC(AYUSH) dt.30
th
September 2016 issued
by the Government of India , Ministry of Ayush . Para No 2 mentions the tentative list of diseases/
disease conditions needing hospitalization of the patients, indicative therapies and likely duration
of hospitalization. Para No. 3 gives the benchmark costing of Ayurvedic Therapies/interventions
procedure including cost of medicines used in the procedure.
Forum observes that the Chief complaint of the complainant and the treatment falls under Sl.No.
3 of the list and the corresponding indicated therapies and likely duration of hospitalization are
correlating with the discharge summary of the complainant. The Forum also notes that the
hospital charged lesser than the indicated cost towards Abhyanga, Abhyanga-Sthanika and for
Abhyanga+ Sweda.
Hence this Forum finds that the treatment of Abhyanga, Abhyanga-Sthanika and Abhyanga+
Sweda given to the complainant are active line of treatment in accordance to her diagnosis as per
Duscharge Summary. Hence rejection of Ayurvedic treatment claim on the ground of Condition
No.10 of policy terms are not in order.
The complainant applied for reimbursement of medical expenses with the RI claiming for
Hospitalization Main Bill Rs.35,625/-, Post Hospitalization Rs.3049/-, Pharmacy Bill Rs.8703/-
Totalling to Rs.47,377/- . The R.I submitted calculation of claim amount payable without prejudice
for Rs. 39,895/- by deducting Rs.7482/-(Breakup with reason Rs.3049/- Bills not available +
Rs.4433/- 10% Non-network Co-pay applicable). The Forum observed that the complainant also
did not produce appropriate bills to the Forum in support of claiming post hospitalization
treatment.
In view of the above, the R.I is directed to settle claim by reducing post hospitalization claim
amount of Rs.3049/- and Co-pay , out of Rs.47,377/- as per policy terms and conditions . The R.I is
further directed to settle the post hospitalization expenses after procuring proof of receipt and
relevant documents from the complainant.
The complainant is advised to submit the post hospitalization bills along with required documents
to the R.I for their settlement of Rs.3049/-.
Hence the complaint is Partially Allowed.
A W A R D
Taking into account of the facts and circumstances of the case, the documents and the oral
submissions made by both the parties, this Forum does not concur with the decision of the
Respondent Insurer in restricting the claim in accordance with the terms and conditions of
policy.
This Forum directs the Respondent Insurer to settle the claim by reducing post
hospitalization claim amount of Rs.3049/- and Co-pay, out of Rs.47,377/- as per policy
terms and conditions from the date of receipt of last necessary documents to the date of
payment of claim, along with interest as per regulation 16 (1) (ii) of Protection of Policy
Holders’ Interests Regulations, 2017 issued vide notification dated 22.06.2017.
The R.I is further directed to settle the post hospitalization expenses after procuring proof
of receipt and relevant documents from the complainant.
The complainant is advised to submit the post hospitalization bills along with required
documents to the R.I for their settlement of Rs.3049/-.
Hence, the complaint is Partially Allowed
Attention of the Complainant and the Insurer is hereby invited to the following:
a. The Complainant shall submit all requirements/Documents required for settlement of award
within 15 days of receipt of the award to the Respondent Insurer.
b. According to Rule 17(6) of the Insurance Ombudsman Rules, 2017, the insurer shall comply
with the award within thirty days of the receipt of the award and intimate compliance of the
same to the Ombudsman.
Dated at Bangalore on the 28
th
day of JANUARY 2021.
(NEERJA SHAH)
INSURANCE OMBUDSMAN
FOR THE STATE OF KARNATAKA
PROCEEDINGS BEFORE - THE INSURANCE OMBUDSMAN, STATE OF M.P. & C.G.
(UNDER RULE NO: 16(1)/17 OF THE INSURANCE OMBUDSMAN RULE 2017)
OMBUDSMAN – G S SHRIVASTAVA
Mr.Kuldeep Singh Arora …..…….....…………………..……………….………………….….……...…..Complainant
V/s
United India Insurance Co. Ltd. …………….....…….……………….…….……...……………….……Respondent
COMPLAINT NO: BHP-H -051-2021-0140 ORDER NO: IO/BHP/A/ HI / 0053 /2020-2021
1.
Name & Address of the
Complainant
Mr. Kuldeep Singh Arora
25, Girdhar Nagar, Tilak Nagar
Indore
2.
Policy No:
Type of Policy
Duration of policy/Policy period
500100/28/18P114024582
Tailormade Group Mediclaim Policy (Retirees)
01.11.2018 – 31.10.2019
3.
Name of the insured
Name of the policyholder
Mr. Kuldeep Singh Arora
Mr. Kuldeep Singh Arora
4.
Name of the insurer
United India Insurance Co. Ltd
5.
Date of Repudiation/ Rejection
--
6.
Reason for Repudiation/ Rejection
--
7.
Date of receipt of the Complaint
23.11.2020
8.
Nature of complaint
Partial settlement of claim
9.
Amount of Claim
Rs. 30,676/-
10.
Date of Partial Settlement
16.09.2019, 18.09.2019,
25.10.2019,24.10.2019, 7.11.2019,
11.
Amount of relief sought
Rs. 30,676/-
12.
Complaint registered under Rule
Rule No. 13(1)(b) Ins. Ombudsman Rule 2017
Mr. Kuldip Singh Arora (Complainant) has filed a complaint against United India Insurance
Company Ltd.(Respondent) alleging partial settlement of the claim.
Brief facts of the case –
Contention of the complainant –The Complainant has stated that he had purchased
mediclaim policy – basic under IBA 4.0 + 5Lakhs Top Up on 01.11.2018 & 01.11.2019
Details of medical expenses for Liver and Colon Cancer were made, details as under :
S.No.
Date
Details of bills
lodged
Amount
lodged
Rs.
Amount
Sanctioned
Amount
Rejected
Rs.
Reason for
Rejection
1
25.03.2019
Operation for
Cancer in
Colon & Liver
6,48,232/
6,41,919/-
6313/-
Tegaderm
Dressing for
Chemotherapy
Not allowed
2.
29.06.2019
Chemotherapy
77,313/-
68,359/-
8954/-
Bills not received
3
2.12.2019
Colonoscopy &
Pathology
15,409/-
0
15,409/
Colonoscopy not
considered
Total Amount
Rejected
30,676/
The Med Assists TPA of New India Assurance Co. Ltd. sanctioned 70% claim applicable to
parents of his son amounting to Rs. 2.91 lakhs, the remaining 30% was sanctioned by United
India TPA MDI Rs.1.25 Lakhs. This claim by United India included expenses for Tegaderm
dressing used in Chemotherapy but declined Rs.6313/- in the subsequent claims. He forgot to
mention bill no. 8269190 dated 22.05.2019 for Rs.4075/- and # 8269853 dated 23.05.2019
for Rs.4879/- from Tata Memorial Hospital, total Rs.8954/- with the total 56 bills for
Rs.77,313/- so mentioned Rs.68,359/. This insurance Co. sanctioned but denied having
received two receipts for Rs.8954/- and did not pay the amount. However he had sent the
original receipts for deposits of expenses made as mentioned along with original statement
of his account with Tata Memorial Hospital from December 18 to August 19. This contained
all entries he spent during the course of his treatment. This is adequate proof of having
spent the money. But United India Ins. Co. did not sanction the amount. On 1919.11.2019 he
went for Colonoscopy and Pathology tests and submitted his claim of Rs. 15,409/- on
02.12.2019. United India Insurance Co. denied with the reason Pre/ Post operative
treatment expenses not allowed. The complainant states that here its worth mentioning that
he had renewed his mediclaim policy w.e.f 01.11.2019 for Rs. 4.00 Lakhs IBA + 5.00 Lakhs Top
13.
Date of hearing/place
On 05.01.2021 at Bhopal
14.
Representation at the hearing
For the Complainant
Mr Kuldeep Singh Arora over Go To Meet App
For the insurer
Ms Pamela Pinto, Dy Manager over Go To
Meet App
15.
Complaint how disposed
Allowed
16.
Date of Award/Order
05.01.2021
Up. Thus his basic policy of 4.00 lakhs was available to cover his pre/ post operative
expenses. Thus he has been denied his rightful claim.
Contention of respondent - The respondent in their SCN have stated as under : -
HOSPITALISATION DETAILS:
Name of Hospital : Tata Memorial Hospital – Mumbai / Suyash Hospital Pvt. Ltd. Indore, Date
of Admission : 20.02.2019 & 28.03.2019, Date of Discharge : 09.03.2019 & 20.06.2019,
Diagnosis : Sigmoid Colon with Hepatic Metastasis, Sum Insured : Rs. 5,00,000/-. Claim
Amount : Rs. 6,09,237/- & Rs. 68,359/- . The Company has received claim documents under
Policy No. 500100/28/18/P114024582 for patient, Arora Kuldeep Singh, patient is covered
under, Indian Banks Association/ Bank of Maharashtra Retired Employee (TOP UP POLICY).
Patient was admitted in Tata Memorial Hospital - Mumbai/ Suyash Hospital Pvt. Ltd. – Indore
from 20.02.2019 to 09.03.2019 & various dates from 28.03.2019 to 20.06.2019 respectively
for the treatment of Sigmoid Colon with Hepatic Metastasis. After discharge from the
hospital insured had submitted claim documents for reimbursement claim for the amount of
Rs.6,09,237/- & Rs.68,359/- 1) Claim No. MDI4876447 for Rs.6,09,237/- Corporate Name :
India Banks Association/ Bank of Maharashtra, retired employee (Top- up Policy). Policy No.
500100/28/18/P114024582, MDID – MD15-0032269258, Patient Name : Arora Kuldeep
Singh, DOA: 20.02.2019 - DOD : 09.03.2019 , Diagnosis : Sigmoid Colon with Hepatic
Metastasis, Treatment: Chemotherapy parenteral.
Claim lodged for
6,09,237/-
Paid under Base Policy – CCNMDI4862177
-2,75,126/-
Paid on 16.09.2019
-51,288/-
Paid on 18.09.2019
-1,90,631/-
Amount not paid (Deductions)
92,192/-
Deductions : Rs. 105/- towards medicine considered twice. Rs. 5829/- towards Tegaderm
which is not payable. Rs.86,258/- Pharmacy Bills not available. Additional amount of Rs.
15,409/- claimed towards expenses for Colonoscopy, FUC, USG etc done in Nov. 19 denied as
fresh policy taken from 01.11.2019 to 31.10.2020. As they cross checked claim is for only
investigations and medicines charges and if they were to process the claim under new 2019-
20 policy, there also they will repudiate the claim as OPD not covered under IBA/BOM/
Retiree Option 1 policy (Without Domiciliary). If the Company were to process the claim as
additional claim of previous claim paid claim, then also they cannot settle the claim since it is
Top Up Policy where Pre & post hospitalization is not covered. Hence claim for Rs. 15,409/-
which has been repudiated is in order. 2) Claim No. MDI5015303. Corporate Name : India
Banks Association/ Bank of Maharashtra, retired employee (Top- up Policy). Policy No.
500100/28/18/P114024582, MDID – MD15-0032269258, Patient Name : Arora Kuldeep
Singh, DOA: 28.03.2019 - DOD : 20.06.2020, Diagnosis : Sigmoid Colon with Hepatic
Metastasis, Treatment: Chemotherapy parenteral. A) Main claim lodged amount – Rs.
68,359/- Main claim
Settled amount Rs.33,762/- + Rs.34,597/- = Rs.68,359/- B) Additional Claim 1 lodged amount
– Rs.38,170/-, Additional claim settled amount Rs.14,242/- + Rs.23,928/- = Rs.38,170/- C)
Additional 2
nd
claim lodged amount – Rs.8954/-. As the Company cross checked claim
documents they have received photocopy bills for Rs.4879/- and Rs.4075/-.Hence the
Company needs original bills for further processing.
The Complainant has filed complaint letter, Annex. VIA and correspondence with
respondent while respondent have filed SCN with enclosures.
I have heard both parties over Go To Meet App at length and perused paper filed on behalf
of the complainant as well as the Insurance Company.
Observation and Conclusion : Complainant has filed a complaint stating that an amount of
Rs.30,676/- was not paid by the respondent in claims lodged by him. As per complainant,
respondent had not allowed an amount of Rs.8,954/- as original bills not received and
Rs.15,409/- for colonoscopy and Rs.6,313/- towards Tegaderm dressing for chemotherapy.
During hearing, representative of the respondent has stated that original bills for Rs.8,954/-
were not received and shall be considered by them on the basis photocopies available with
them. The representative has further stated that amount of Rs.15,409/- shall be considered
under the policy for the year 2019-2020 as it falls under Day Care. She has further stated
that amount of Rs.4,867/- with respect to Tegaderm expenses, they shall pay as per IRDA
rules. After hearing, respondent has sent an email in which they have mentioned that
1)amount of Rs,8,954/- bills not paid shall be considered by them on the basis of
photocopies available with them. 2) Rs.15,409/- amount not paid towards Colonoscopy and
other tests done in November, 2019, the same shall be considered under the policy for the
year 2019-2020 and 3) Tegaderm expenses Rs.4,867/- which was disallowed, they shall pay
as per IRDA Rules wherein 3 Tegaderm dressings for first 24 hours and one for next 48
hours. Complainant has complained for an amount of Rs.6,313/- with respect to Tegaderm
dressing while respondent has submitted bills filed by the complainant in which total
expenses with respect to Tegaderm dressing comes to Rs.4,867/- which is in conformity with
the amount mentioned in email. As during hearing as well as in email received after
hearing, respondent is ready to consider all the three amounts which were not paid to the
complainant, complaint is liable to be allowed.
Let copies of the order be given to both the parties
Dated : Jan 05, 2021 G.S.Shrivastava
Place : Bhopal Insurance Ombudsman
PROCEEDINGS BEFORE
AWARD
In view of above facts and circumstances, complaint filed by Mr Kuldeep Singh Arora stands
allowed with directions to the respondent that all the three impugned amounts be allowed
as per their email dated 05.01.2021 sent to this forum. Compliance shall be made within 30
days from the date of receipt of this award.
THE INSURANCE OMBUDSMAN, STATE OF ODISHA, BHUBANESWAR
(UNDER RULE NO: 16(1)/17 OF THE INSURANCE OMBUDSMAN RULES, 2017)
OMBUDSMAN – Shri Suresh Chandra Panda
CASE OF Mr. Ajaya Kumar Das Vrs. Cholamandalam MS General Insurance Co. Ltd
COMPLAINT REF: NO: BHU-H-012-2021-0094
AWARD NO: IO/BHU/A/HI/ /2020-21
1.
Name & Address of the
Complainant
Mr. Ajaya Kumar Das
At: Gudianali, PO/Dist: Dhenkanal, Odisha-759001
Mobile No. 9861831302
2
Policy No:
Type of Policy
Duration of policy/Policy
period
2876/00028670/000001/000/00, Group Health
Insurance
10/10/2019 to 09/10/2020
Date of admission 14/08/2020 D.O.D. 23/08/2020
Again
28/08/2020 to 02/09/2020 and 06/10/2020 to
12/10/2020
3.
Name of the insured
Name of the policyholder
Mr. Ajaya Kumar Das
Mr. Ajaya Kumar Das
4.
Name of the insurer
Cholamandalam MS General Insurance Co. Ltd
5.
Date of Repudiation
06/10/2020
Pre-existing disease (waiting period 24 months)
6.
Reason for repudiation
7.
Dt. of receipt of the
Complaint
21/10/2020
8.
Nature of complaint
Requested to advice the Insurer to settle the claim
9.
Amount of Claim
Rs. 4,50,000/-
10.
Date of Partial Settlement
Not applicable
11.
Amount of relief sought
Rs 4,50,000/-
12.
Complaint registered under
Rule no: of IO rules
13(1)b
13.
Date of hearing/place
22/01/2021, Bhubaneswar
14.
Representation at the
hearing
a) For the Complainant
Mr. Aman Kumar Das (Son of the applicant)
b) For the insurer
Dr. Prabhu M through VC
15
Complaint how disposed
U/R 16(1) of the Insurance Ombudsman Rules, 2017
16
Date of Award/Order
27.01.2021
17. a. Brief Facts of the Case/Cause of Complaint: - The Complainant is covered under policy
No. 2876/00028670/000001/000/00 for the period from 10/10/2019 to 09/10/2020 having sum
insured of Rs.7,50,000/- declaring pre-existing diseases of diabetes, hypertension and heart
operation in 2014. Within one month from the inception of the policy the complainant was
diagnosed of cancer and got treated at his own expenses, came back to normal life. After four
months from the completion of cancer treatment, he had severe back pain and diagnosis revealed
that he has metastasis in spine and was admitted in Utkal Hospital, Bhubaneswar on 14/08/2020
and discharged on 23/08/2020. He s again hospitalised from 28/08/2020 to 02/09/2020 and
06/10/2020 to 12/10/2020. He had applied for cash-less treatment which was denied by the
insurer, subsequently he lodged a re-imbursement claim and the same was repudiated on the
ground, the complication associated with cancer, hence the same is not admissible till 2 years of
policy inception. Being aggrieved the complainant made an appeal before this forum for redressal.
b. The insurer in the self-contained note stated that Health policy No.2876/00028670 was issued
to the complainant, a customer of Union Bank of India for the period from 10.10.2019 to
09.10.2020. On receipt of request for Pre-authorisation for cash less settlement through Utkal
Institute of Medical Science & Hospital, they have responded immediately and requested below
mentioned information to treating Doctor vide their letter dated 19/08/2020.
1. previous year policy copy. 2. the details of the incident leading to the injury including time,
date, place and mode of injury along with a copy of MLC and specify whether the patient was
under the influence of any substance abuse at the time of incident. 3. treating doctors certificate
stating likely ETIOLOGY of the present ailment and detailed plan of treatment. For the above
queries, hospital has responded as under and also provided clinical reports.1. This is the first-year
policy, 2. There was no history of injury, 3. It is a case of CA Metastases
On perusal of above documents, the insurer observed that the complainant was suffering from a
metastatic lesion and was undergoing procedure. Metastatic lesion does not occur immediately
and will be associated with a Carcinoma which is a primary lesion in the body. In view of above
observations, they have informed to aforesaid hospital vide their letter dt.20.8.2020 that, they
cannot issue Authorisation letter for cash less settlement as the PED to the present treatment
cannot be ruled out. A denial of cashless access is NOT to be considered in any way as a denial of
treatment. The Insured can send a request for consideration through reimbursement within 30
days from the date of discharge. They have not received request for the claim along with Bills and
relevant supportive documents for their perusal. The complainant was again admitted on
3.10.2020 for further treatment for the same disease. As the disease is pre-existing one, pre-
authorisation is denied. They furnished the relevant definitions and exclusions of the policy as
under
2.46 -Definition of Pre-existing Disease:
Pre-Existing Diseases means any condition, ailment or injury or related condition(s) for which
there were signs or symptoms, and / or were diagnosed, and / or for which medical advice /
treatment was received within 48 months prior to the first policy issued by the insurer and
renewed continuously thereafter
3.1 Pre-Existing Disease (PED)
Benefits will not be available for any pre-existing condition(s) as defined in the policy, until 24
consecutive months of continuous coverage have elapsed, since inception of the first policy with
Us.
58.1 Cancer of Specified Severity
I. A malignant tumor characterized by the uncontrolled growth and spread of malignant cells with
invasion and destruction of normal tissues. This diagnosis must be supported by histological
evidence of malignancy. The term cancer includes leukemia, lymphoma and sarcoma.
II. The following are excluded –
i. All tumors which are histologically described as carcinoma in situ, benign, pre-malignant,
borderline
malignant, low malignant potential, neoplasm of unknown behavior, or non-invasive, including
but not limited to: Carcinoma in situ of breasts, Cervical dysplasia CIN-1, CIN - 2 and CIN-3.
ii. Any non-melanoma skin carcinoma unless there is evidence of metastases to lymph nodes or
beyond;
iii. Malignant melanoma that has not caused invasion beyond the epidermis;
iv. All tumors of the prostate unless histologically classified as having a Gleason score greater than
6 or having progressed to at least clinical TNM classification T2N0M0
v. All Thyroid cancers histologically classified as T1N0M0 (TNM Classification) or below;
vi. Chronic lymphocytic leukaemia less than RAI stage 3
vii. Non-invasive papillary cancer of the bladder histologically described as TaN0M0 or of a lesser
classification,
viii.All Gastro-Intestinal Stromal Tumors histologically classified as T1N0M0 (TNM Classification) or
below and with mitotic count of less than or equal to 5/50 HPFs;
ix. All tumors in the presence of HIV infection.
18. a. Complainant’s Argument: It is not a Pre-existing disease and the claim is payable.
b. Insurer’s Argument: Present admission is towards Fracture of vertebra due to metastases of the
bone (vertebra) which is the complication associated with cancer, hence the same is not
admissible till 2 years of policy inception so they repudiated the claim.
19. Reason for Registration of Complaint: Scope of the Insurance Ombudsman Rules, 2017
20. The following documents are placed in the file.
a. Policy copy and clauses
b. Photo copy of medical report and bills.
21. Result of hearing with both parties (Observations & Conclusion): - This Forum has carefully
gone through all the documents and papers relating the complaint and heard both the parties.
The complainant stated that his father was first treated for cancer in November,2019 after the
policy was incepted. He also informed that the insurer hardly responded to the claims in spite of
regular follow-ups. The complainant has played the voice recording he had with Mr. Abhay Ku
Singh of the insurer from Patna, in which the insurer confirmed that the complainant will get the
claim for some amount, may not necessarily the full amount. The conversation was in Hindi which
says “Paisa miljaega, full nehin milega, lekin kuchh miljaega”. But the insurer declined the claim
because the case involved a probability of PED. It is found that the insurer, vide mail dated
08.09.2020, has stated that the information provided in relation of PED to the present case cannot
be ruled out and insurer was infected with cancer before buying the policy. The mail dated
28.09.2020 of the insurer confirmed the discussion had with the complainant’s son and asked for
the documents for reimbursement. During hearing the insurer stated that the complainant has
not submitted the original documents, which is also admitted by the complainant’s son.
22. The attention of the complainant and the Insurer is hereby invited to the following
provisions of Insurance Ombudsman Rule,2017: a. According to Rule 17(6) of Insurance
Ombudsman Rules,2017, the Insurer shall comply with the award within 30 days of the receipt
of the award and shall intimate the compliance of the same to the Ombudsman. b. As per Rule
17(8) of the said rules, the award of Insurance Ombudsman shall be binding on the Insurers.
Dated at Bhubaneswar on the 27
th
day of January, 2021 INSURANCE OMBUDSMAN
FOR THE STATE OF ODISHA
AWARD
Taking into account the facts and circumstances of the case and submissions made by
both the parties during the course of hearing, the forum finds that the insurer was
deficient in service by not responding the complainant timely during cash-less or during
reimbursement process. The insurer’s stand, for denial stating there being a probability
of PED, has no substance as it is based on assumptions and not based on any authentic
proof. Moreover, the insurer’s telephonic assurance of paying the claim followed by a
mail, has assured the complainant that he would certainly get the claim. Considering
the facts expressed during hearing and submitted on documents, the Forum is of the
view that the insurer cannot deny the claim on presumptions and probabilities and the
claim is payable. Since the complainant has not submitted the original documents, he is
advised to submit the same to the insurer immediately within 15 days of receipt of this
order. The insurer is directed to process and settle the claim within 30 days of receipt
of the documents.
Accordingly, the complaint is allowed.
PROCEEDINGS BEFORE
THE INSURANCE OMBUDSMAN, STATE OF ODISHA, BHUBANESWAR
(UNDER RULE NO: 16(1)/17 OF THE INSURANCE OMBUDSMAN RULES, 2017)
OMBUDSMAN – Shri Suresh Chandra Panda
CASE OF Mr. Rashmi Ranjan Sahoo Vrs. IFFCO Tokio General Insurance Co. Ltd
COMPLAINT REF: NO: BHU-H-023-2021-0099
AWARD NO: IO/BHU/A/HI/ /2020-21
1.
Name & Address of the
Complainant
Mr. Rashmi Ranjan Sahoo,
Netaji Nagar, Near Panchamukhi Hanuman Temple
PO; Madhupatana, Cuttack-753010, Mobile No.
8328873103
2
Policy No:
Type of Policy
Duration of policy/Policy
period
H0037401, Group Medishield Insurance Policy
08/11/2018 to 07/11/2019
Date of admission 04/05/2019 to 10/05/2019
And 26/05/2019 to 01/06/2019
3.
Name of the insured
Name of the policyholder
Mr. Rashmi Ranjan Sahoo
Mr Rashmi Ranjan Sahoo
4.
Name of the insurer
IFFCO Tokio General Insurance Co. Ltd
5.
Date of Repudiation
Not applicable (partially settled.)
Not applicable (Partially settled.)
6.
Reason for repudiation
7.
Dt. of receipt of the
Complaint
01/10/2020
8.
Nature of complaint
Requested to advice the Insurer to Settle balance
amount of claim.
9.
Amount of Claim
Rs. 40,084/-
10.
Date of Partial Settlement
09/10/2020 & 13/10/2020
11.
Amount of relief sought
Rs. 40,084/-
12.
Complaint registered under
Rule no: of IO rules
13(1)b
13.
Date of hearing/place
22/01/2021, Bhubaneswar
14.
Representation at the
hearing
a) For the Complainant
Self through VC
b) For the insurer
Mr. Suraj Singh Negi, through VC from Gurgaon
15
Complaint how disposed
U/R 16(1) of the Insurance Ombudsman Rules, 2017
16
Date of Award/Order
27/01/2021
17. a. Brief Facts of the Case/Cause of Complaint: - The Complainant is covered under Group
Mediclaim policy vide No. H0037401 for the period from 08/11/2018 to 07/11/2019 for sum
Insured of Rs.2,00,000/-. He was hospitalised two times i.e., from 04/05/2019 to 10/05/2019 and
26/05/2019 to 01/06/2019 in Prime Multispeciality Hospital, Link Road, Cuttack and lodged claims
for Rs. 46,600/- and 42,889/- respectively which was settled by the Insurer for Rs. 24,534/- and Rs.
24,871/-. Being aggrieved with partial settlement the complainant made an appeal before this
forum for redressal.
b. The insurer in their self-contained note stated that they had issued a Group Mediclaim policy
No. H0037401 to SBI Life Insurance Co. Ltd for the period from 08/11/2018 to 07/11/2019, the
complainant was covered under the said policy for Sum Insured of Rs.2,00,000/-. The complainant
was hospitalised in Prime Multispeciality Hospital from 04/05/2019 to 10/05/2019 with diagnosis
of wounded avulsion injury right foot with skin erosion and submitted the claim for Rs.46,600/-. In
the second claim the complainant was hospitalised from 26/05/2019 to 01/06/2019 with
diagnosis of post trauma raw area right dorsum of foot and submitted claim for Rs.42,889/-. On
examination of claim documents, it was found that the proper pre numbered payment receipt for
balance amount for both the cases were not submitted. Hence, both the claims were processed
after making the deduction on account of improper payment receipt for balance amount. The
claim No.10621920100858 was settled for Rs.24,534/- and claim No. 10621920359146 was
settled for Rs.24,871/-. Copy of claim settlement vouchers along with deduction reasons are in the
file. Further, for the deducted amount on account of non-submission of pre-numbered payment
receipt, they are taking up the matter with respective Hospital to check the authenticity of the
receipt and shall update to Honourable Forum accordingly.
18. a. Complainant’s Argument: Though he has submitted all the documents still the insurer
settled the claim partially deducting Rs.40,084/-.
Insurer’s Argument: The reported claims have been paid correctly as per policy and for the
deducted amount on account of non-submission of pre-numbered payment receipt, the matter is
under investigation.
19. Reason for Registration of Complaint: Scope of the Insurance Ombudsman Rules, 2017
20. The following documents are placed in the file.
a. Policy copy and clauses, b. Photo copy of bills and hospital papers.
21. Result of hearing with both parties (Observations & Conclusion): - This Forum has carefully
gone through all the documents and papers relating the complaint and heard both the parties. It
is observed that the insurer has partially paid the claim and the balance claim is not paid for the
reason stating that the complainant has not submitted proper pre-numbered receipts for the
balance claim amount. The complainant stated that he has submitted all receipts which are issued
by the hospital and are pre-numbered with only exception that the receipts are printed manual
receipts in place of computer-generated copies. He also stated that he has submitted a certificate
from the hospital confirming the receipts issued by the later. The insurer in their SCN have
submitted that the investigation is still on. The complainant stated that he was harassed by the
insurer as the latter never bothered to settle the claim till this complaint was filed before this
Forum. The insurer, during hearing, informed that since the paid receipts were not proper, they
did not consider the said receipts and paid for correct receipts. They had paid partial claim as
there were deficiencies in money receipts.
22. The attention of the complainant and the Insurer is hereby invited to the following provisions
of Insurance Ombudsman Rule,2017: -a. According to Rule 17(6) of Insurance Ombudsman
Rules,2017, the Insurer shall comply with the award within 30 days of the receipt of the award
and shall intimate the compliance of the same to the Ombudsman. b. As per Rule 17(8) of the said
rules, the award of Insurance Ombudsman shall be binding on the Insurers.
Dated at Bhubaneswar on the 27
th
day of January, 2021 INSURANCE OMBUDSMAN
FOR THE STATE OF ODISHA
AWARD
Taking into account the facts and circumstances of the case and submissions made by
both the parties during the course of hearing, the forum finds that some money
receipts, which are not considered by the insurer, are issued manually on printed
receipts. It is found that the money receipts are issued by the hospital and are
properly numbered. It is also found that the hospital, vide a written responded on
25.11.2019 and confirmed to the insurer that they have issued the said receipts. Under
the above facts, the forum does not find any reason as to why the balance claim
amount cannot be considered. Therefore, the insurer is directed to settle the balance
amount of Rs. 40084/- subject to necessary deductions towards excess and non-
payable items if any. Copy of the Hospital response dated 25.11.2019 be attached with
this order for insurer’s record.
Accordingly, the complaint is allowed.
PROCEEDINGS BEFORETHE INSURANCE OMBUDSMAN, CHANDIGARH
(UNDER INSURANCE OMBUDSMAN RULES, 2017)
INSURANCE OMBUDSMAN- Dr. D.K. VERMA
Case of Mr. Prince V/S Future Generali India Insurance Co. Ltd.
COMPLAINT REF. NO: CHD-H-016-2021-0358
1.
Name & Address of the Complainant
Mr. Prince
# 550, Main Road, Khera Wali Gali, Jyotisar
Josar, 428, Kurukshetra,
Haryana- 136119
Mobile No.- 9780388236
2.
Policy No:
Type of Policy
Duration of policy/Policy period
FGS-37-19-700496-00-000
Group Health Policy
31-07-2019 to 30-07-2020
3.
Name of the insured
Name of the policyholder
Mr.Prince / Ms. Anjali
Rockpecker Private Limited
4.
Name of the insurer
Future Generali India Insurance Co. Ltd.
5.
Date of Repudiation
NA
6.
Reason for repudiation
NA
7.
Date of receipt of the Complaint
19-10-2020
8.
Nature of complaint
Deduction in claim
9.
Amount of Claim
Rs.23011/-
10.
Date of Partial Settlement
Not provided
11.
Amount of relief sought
Rs. 23011/-
12.
Complaint registered under
Rule no: Insurance Ombudsman Rules,
2017
Rule 13 (1)(b) – any partial or total repudiation
of claim by an insurer
13.
Date of hearing/place
05.01.2021/ Chandigarh/Through VC
14.
Representation at the hearing
For the Complainant
Mr. Prince
For the insurer
Dr.Akanksha Saxena
15
Complaint how disposed
Dismissed
16
Date of Award/Order
18.01.2021
17) Brief Facts of the Case:
On 19-10-2020, Mr. Prince had filed a complaint vide which he informed that his wife Mrs. Anjali was
pregnant with four babies. Her case was critical and refereed to PGI, Chandigarh. She has also taken
treatment from Kamboj Multi Specialty hospital. As per doctor’s advice, her two babies were aborted in 4
th
Month. In 7
th
month premature delivery has been performed in PGI. 3
rd
baby died in her womb and 4
th
baby died after ½ an hour after delivery. Total expenses incurred during delivery including pre and post
hospitalization are Rs. 26329/- but insurance company has allowed Rs. 3318/- only and decline Rs.23011/-
on the ground that pre and post natal treatment covered with in the maternity limits in case of
hospitalization only. As pre policy pre and post hospitalization are covered 30 days and 60 days
respectively so insurance company cannot deny the claim and more over total expenses met are within the
frame work of the policy. He requested for payment of rest of the expenses i.e. Rs. 23011/- retained
wrongly by them.
On 02-11-2020, the complaint was forwarded to Future Generali India Insurance Co. Ltd. Regional Office,
Chandigarh, for Para-wise comments and submission of a self-contained note about facts of the case,
which was made available to this office on 10-11-2020. The complainant was sent Annexure VI-A for
compliance, which reached this office on 05-11-2020.
As per SCN of company they had issued a Group Health Insurance Policy no. FGS-37-19-7000496-00-000
for the period 31-Jul-19 to 30-Jul-20 in favour of insured Rockpecker Pvt. Ltd., being a bonafide employee,
insured member is covered under the policy. Insured had reported a claim on 15th-Jul-2020 for Spouse as
she has undergone hospitalization for “Maternity- Premature Labour at 20 wks- Spontaneous Expulsion of
Twin Aborts”. Total claimed amount was INR 26329/- The expense related to hospitalization is paid to
client.
The definition of Maternity as per policy conditions is given below:
Definitions III. 27. Maternity expense: Maternity expense means
a. Medical treatment expenses traceable to childbirth (including complicated deliveries and
caesarean sections incurred during hospitalization)
b. Expenses towards lawful medical termination of pregnancy during the policy period.
Since policy covers medical expense related to Maternity and its complication for hospitalization only, pre
and post-natal expenses were deducted. Following are the excerpts of policy copy (Annexure A, page 5,
point 2)
“Pre and Post-natal treatment covered within the maternity limits in case of hospitalization only”
18) Cause of Complaint:
a) Complainant’s argument: Insurance Company has not paid their genuine claim in full and
deducted most of claimed amount on wrong grounds, also ignoring lock down situation at that
time.
b) Insurers’ argument: Claim is settled as per terms and conditions of the policy.
19) Reason for Registration of Complaint:- within the scope of the Insurance Ombudsman Rules, 2017.
20) The following documents were placed for perusal.
a) Complaint to the Company b) Copy of Policy Document
c) Annexure VI-A d) Reply of the Insurance Company
21) Result of Personal hearing with both parties(Observations & Conclusion)
In above case, Complainant’s wife Mrs. Anjali was pregnant with four babies. Unfortunately, her two
bodies were aborted in 4
th
month, 3
rd
baby died in her womb and 4
th
baby died after an hour after delivery.
She remained hospitalized in PGI, Chandigarh from 03.07.2020 to 06.07.2020. Out of total claimed amount
of Rs. 26329/- for related treatment, insurance company has approved Rs.3318 only. For deduction,
insurance company informed that since policy covers medical expenses related to maternity and its
complication for hospitalization only, pre and post natal expenses were deducted. Complainant informed
that due to lockdown they couldn’t go to PGI earlier then 13.05.20. He reiterated that all expenses
including testing are related to pregnancy only, which is covered under the policy. Besides medical papers
including bills raised under claim, I have seen relevant special condition no. 2 of policy, quoted by
Insurance Company which states that pre and post natal treatment covered within the maternity limits in
case of hospitalization only. On perusal of various related documents and considering submissions made by
complainant as well as representative of insurance company I am of the opinion that due to special
condition under the relevant policy, decision of insurance company regarding deductions made under the
claim being as per terms and conditions of the policy, the same does not warrant any interference.
Accordingly the said complaint is hereby dismissed and no relief is granted.
AWARD
Taking into account the facts & circumstances of the case and the submissions made by both the
parties during the course of hearing held through video conferencing, the said complaint is
hereby dismissed on merits.
Hence, the complaint is treated as closed.
Dated at Chandigarh on 18
th
day of January, 2021.
D.K. VERMA
INSURANCE OMBUDSMAN
PROCEEDINGS BEFORETHE INSURANCE OMBUDSMAN, CHANDIGARH
(UNDER INSURANCE OMBUDSMAN RULES, 2017)
INSURANCE OMBUDSMAN- Dr. D.K. VERMA
Case of Mr. Nasib Singh V/S The United India Insurance Co. Ltd.
COMPLAINT REF. NO: CHD-H-051-2021-0398
1.
Name & Address of the Complainant
Mr. Nasib Singh
# H. No.- 640, Phase-10, Mohali, Punjab-0
Mobile No.- 842769240
2.
Policy No:
Type of Policy
Duration of policy/Policy period
5001002819P112263948
Group Mediclaim
01.11.2019 TO 31.10.2020
3.
Name of the insured
Name of the policyholder
Mr. Nasib Singh
IBA A/C PNB
4.
Name of the insurer
The United India Insurance Co. Ltd.
5.
Date of Repudiation
04.09.2020
6.
Reason for repudiation
Day care procedure
7.
Date of receipt of the Complaint
20-11-2020
8.
Nature of complaint
Repudiation of claim
9.
Amount of Claim
Rs. 50700/-
10.
Date of Partial Settlement
NA
11.
Amount of relief sought
Rs. 50700/-
12.
Complaint registered under
Rule no: Insurance Ombudsman Rules,
2017
Rule 13 (1)(b) – any partial or total repudiation
of claim by an insurer
13.
Date of hearing/place
05.01.2021/ Chandigarh
14.
Representation at the hearing
For the Complainant
Mr.Nasib Singh (in person)
For the insurer
Ms. Mamta Bansal (through VC)
15
Complaint how disposed
Award
16
Date of Award/Order
05.01.2021
17) Brief Facts of the Case:
On 20-11-2020, Mr. Nasib Singh had filed a complaint that he is a cancer patient and is under treatment
from PGI, Chandigarh. His insurance company is not reimbursing his medical bills despite the fact that same
bill of previous date have been passed by them. There cannot be two parameters for the same treatment.
He requested for payment of his claim to save his life.
On 24-11-2020, the complaint was forwarded to The United India Insurance Co. Ltd. Regional Office,
Chandigarh, for Para-wise comments and submission of a self-contained note about facts of the case,
which was made available to this office on 01.01.2021. The complainant was sent Annexure VI-A for
compliance, which reached this office on 07-12-2020.
As per SCN received from insurance company, they have received claim documents under Pol.no.
5001002819P112263948 for insured patient Mr. Nasib Singh. Insured is covered under IBA/PNB retired
employee policy without domiciliary. As per available documents, patient was admitted with diagnosed
case of Ca Prostate and underwent treatment with injection Firmagon on Day care basis. The above
procedure is not included in the day care procedure list and so the claim was repudiated under section 3.3
of the policy. Also, the policy does not cover domiciliary treatment.
18) Cause of Complaint:
a) Complainants argument : Insurance company has not paid his genuine claim inspite of the fact
that company has paid previous claims of same treatment.
b) Insurers’ argument: The claim is repudiated as per terms and conditions of the policy as treatment
taken is not covered/allowed as day care procedure.
19) Reason for Registration of Complaint:- within the scope of the Insurance Ombudsman Rules, 2017.
20) The following documents were placed for perusal.
a) Complaint to the Company b) Copy of Policy Document
c) Annexure VI-A d) Reply of the Insurance Company
21) Result of Personal hearing with both parties (Observations & Conclusion)
The claim for treatment taken by complainant Mr.Nasib Singh for Ca Prostate, who underwent treatment
with injection Firmaogon has been denied by insurance company taking recourse of clause 3.1 of policy,
since policy doesn’t cover domiciliary treatment and clause no. 3.3 as treatment taken is not included
under day care procedure list. During hearing, attended by Mr. Nasib Singh in person, he produced the
copies of earlier payments made by company to him for same treatment taken on day care basis. I have
seen various documents including submitted by complainant at the time of hearing and considered
submissions made by both parties during hearing. It is evident from documents that stand taken by
company of denying the relevant claim after allowing same earlier doesn’t seem to be proper. Moreover,
treatment by injection Firmagon In case of carcinoma is a recognized and covered procedure under policy’s
terms and conditions under day care which specifically covered chemotherapy including parental
chemotherapy. Keeping in view the facts of the case and above discussion, insurance company is directed
to pay admissible claim to insured as per policy terms and conditions within 30 days of receipt of award
copy.
AWARD
Taking into account the facts & circumstances of the case and the submissions made by both the
parties during the course of personal hearing, admissible claim as per terms and conditions of
policy is hereby awarded to be paid by the Insurer to the Insured, towards full and final
settlement of the claim.
Hence, the complaint is treated as closed.
Dated at Chandigarh on 5
th
day of January, 2021.
D.K. VERMA
INSURANCE OMBUDSMAN
PROCEEDINGS BEFORETHE INSURANCE OMBUDSMAN, CHANDIGARH
(UNDER INSURANCE OMBUDSMAN RULES, 2017)
INSURANCE OMBUDSMAN- Dr. D.K. VERMA
Case of Mr. Maninder Singh Bhatia V/S The United India Insurance Co. Ltd.
COMPLAINT REF. NO: CHD-H-051-2021-0407
1.
Name & Address of the Complainant
Mr. Maninder Singh Bhatia
H. No.- 10513, Haqiqat Nagar, Haibowal Kalan,
Ludhiana, Punjab-141001
Mobile No.- 9988491002
2.
Policy No:
Type of Policy
Duration of policy/Policy period
5001002818P113603564
Group Mediclaim Policy
From 01.11.2018 to 31.10.2019
3.
Name of the insured
Name of the policyholder
Mr. Maninder Bhatia
IBA A/C Central Bank of India
4.
Name of the insurer
The United India Insurance Co. Ltd.
5.
Date of Repudiation
NA
6.
Reason for repudiation
NA
7.
Date of receipt of the Complaint
20-11-2020
8.
Nature of complaint
Non settlement of claim
9.
Amount of Claim
Rs. 46765/-
10.
Date of Partial Settlement
Not provided
11.
Amount of relief sought
Rs. 46765/-
12.
Complaint registered under
Rule no: Insurance Ombudsman Rules,
2017
Rule 13 (1)(b) – any partial or total repudiation
of claim by an insurer
13.
Date of hearing/place
05.01.2021/ Chandigarh/Through VC
14.
Representation at the hearing
For the Complainant
Mr.M.S.Bhatia
For the insurer
Ms.Mamta Bansal
15
Complaint how disposed
Award
16
Date of Award/Order
06.01.2021
17) Brief Facts of the Case:
On 20-11-2020, Mr. Maninder Singh Bhatia, a retired employee of Central Bank of India had filed a
complaint that he had submitted a claim for Rs. 46765/- on 26.08.2019 through R.O. Ludhiana of Central
Bank of India with requisite documents and bills as post hospitalization incurred for treatment of his wife
Mrs. Rajinder Kaur Bhatia who was treated for ‘Bilateral Knee Osteoarthritis with Virus and Flaxion
deformity from 12.06.2019 to 17.06.2019 at Fortis Hospital Ludhiana to Health India Insurance TPA
Services Pvt. Ltd. He has receipt given by representative of TPA. On 14.08.2020 he has also sent reminded
to United India Ins. Co. Ltd. But until that date neither company nor TPA has paid/replied/responded to his
claim. He requested for payment of his claim with interest as per IRDA HIR 2016 and cost of Rs. 25000/- as
cost of his mental agony.
On 25-11-2020, the complaint was forwarded to The United India Insurance Co. Ltd. Regional Office,
Ludhiana, for Para-wise comments and submission of a self-contained note about facts of the case, which
was made available to this office on 01.01.2021. The complainant was sent Annexure VI-A for compliance,
which reached this office on 03.12.2020.
As per SCN received from insurance company, they have received claim documents of insured patient Mrs.
Rajinder Kaur Bhatia, who was admitted in Fortis Hospital, Ludhiana from 12.06.19 to 17.06.19 and
underwent Bilateral Total Knee Replacement surgery. Hospital claim was settled for Rs. 248600/-. Due to
non compliance of queries raised the pre/post hospitalization claim of Rs.46765/- was closed on
30.03.2020. Queries raised were as under :
1) To provide doctor’s prescription to undergo the investigations
To provide details of receipt dt. 24.07.19 for Rs.900/- and dt.06.08.19 for Rs.900/-
To provide USG Abdomen Report
Cancelled cheque
2) Query for original receipt dt. 16.07.2019 for Rs.15000/- with breakup towards physiotherapy
stands waived off.
3) Rs.18000/- for urinary tract infection is not payable as it is not related to hospitalization diagnosis
and treatment for ‘Bilateral Knee Osteoarthritis with varus and inflexion deformity’ and policy does
not cover domiciliary treatment. Moreover valid GST Numbered receipt not given.
18) Cause of Complaint:
a) Complainants argument : Post hospitalization claim has not been paid by company, inspite of
submission of relevant documents with them.
b) Insurers’ argument: Claim could not been paid due to non submission of requisite documents by
complainant.
19) Reason for Registration of Complaint:- within the scope of the Insurance Ombudsman Rules, 2017.
20) The following documents were placed for perusal.
a) Complaint to the Company b) Copy of Policy Document
c) Annexure VI-A d) Reply of the Insurance Company
21) Result of Personal hearing with both parties (Observations & Conclusion)
On perusal of various documents and considering submissions made by complainant and representative of
insurance company during hearing held through video conferencing, it has been observed that Mrs.
Rajinder Kaur Bhatia, wife of complainant remained admitted in Fortis Hospital from 12.06.19 to 17.06.19
for bilateral total knee replacement. The hospitalization claim has already been settled by company, but
they have not paid claim of post hospitalization expenses incurred by complainant for treatment of his wife
after undergoing knee replacement. As such only dispute remains to be decided about post hospitalization
expenses. As per insurance company they have settled hospital claim for Rs. 248600/- and pre/post
hospitalization claim for Rs. 46765/- was closed on 30.03.2020 due to non-compliance of queries raised by
them.
I have examined various aspects of the case and seen that the complainant underwent physiotherapy for
30 days post discharge and submitted a bill of Rs.15,000/-@ 500 per day as a part of strengthening exercise
post knee replacement which is clearly admissible as per policy terms and conditions and failing within 60
days of relevant hospitalization. Insurance company vides their SCN and during hearing informed that
query for original receipt dt. 16.07.2019 for amount of Rs. 15000/- with break up towards physiotherapy
stands waived off. However, as far as bill of 18000/- is concerned, same is not payable as no proper
breakup of the total amount of claim on account of this or the details about treatment taken for Urinary
tract infection has been filed by complainant. His relying on the certificate of kidney care can’t be accepted
since same does not spell out the treatment taken by patient related to her hospitalization claim. As such
the same is held to be non payable.
For balance amount, i.e. other then above issue of Rs.15000/- & Rs. 18000/-, complainant has not provided
requisite receipts and any prescription for tests undertaken by patient post discharge from hospital. At the
time of hearing, complainant offered to provide the same in respect of all investigation for which claim has
been sought by complainant. Insurance company is directed to pay balance amount as per terms and
conditions of policy subject to submission of requisite documents by complainant within 30 days of receipt
of award copy.
In view of above, insurance company is directed to settle the claim to extent of 15000 on account of
physiotherapy charges and balance amount of above said claim, subject to submissions of documents
including original receipts as per policy terms and conditions within 30 days of receipt of award copy.
AWARD
Taking into account the facts & circumstances of the case and the submissions made by both the
parties during the course of personal hearing, Rs. 15000/- on account of physiotherapy and
balance amount subject to submissions of documents by complainant, is hereby awarded to be
paid by the Insurer to the Insured, towards full and final settlement of the claim.
Hence, the complaint is treated as closed.
Dated at Chandigarh on 06
th
day of January, 2021.
D.K. VERMA
INSURANCE OMBUDSMAN
PROCEEDINGS BEFORETHE INSURANCE OMBUDSMAN, CHANDIGARH
(UNDER INSURANCE OMBUDSMAN RULES, 2017)
INSURANCE OMBUDSMAN- Dr. D.K. VERMA
Case of Mr. Mahesh Kalra V/S The Oriental Insurance Co. Ltd.
COMPLAINT REF. NO: CHD-H-050-2021-0322
1.
Name & Address of the Complainant
Mr. Mahesh Kalra
House No.- 1325, Badshai Bagh Colony,
Ambala City, Ambala, Haryana-0
Mobile No.- 9416297027
2.
Policy No:
Type of Policy
Duration of policy/Policy period
261101/48/2020/1134
Group Health Policy
01-3-2020 To 28-02-2021
3.
Name of the insured
Name of the policyholder
Mr. Mahesh Kalra
4.
Name of the insurer
The Oriental Insurance Co. Ltd.
5.
Date of Repudiation
27.07.2020
6.
Reason for repudiation
Not payable as per policy clause 3.14 and 4.21
7.
Date of receipt of the Complaint
01-10-2020
8.
Nature of complaint
Non-payment of mediclaim
9.
Amount of Claim
More than Rs.65000/- (Three Claims)
10.
Date of Partial Settlement
N. A
11.
Amount of relief sought
Claim amount
12.
Complaint registered under
Rule no: Insurance Ombudsman Rules,
2017
Rule 13 (1)(b) – any partial or total repudiation
of claims by an insurer
13.
Date of hearing/place
12.01.2021 / Online
14.
Representation at the hearing
For the Complainant
Mr. Mahesh Kalra
For the insurer
Mr. Ravi Garg
15
Complaint how disposed
Award
16
Date of Award/Order
21.01.2021
17) Brief Facts of the Case:
On 01-10-2020, Mr. Mahesh Kalra had filed a complaint against The Oriental Insurance Co. Ltd. for
non-payment of medicalim and stated that he is continuous holder of health insurance policy since
2013 and his wife is also covered in it. He further stated that his wife Smt. Prem Lata Kalra is
suffering from cancer since 2018 and is under treatment from PGI Chandigarh. As per the
prescription of PGI claims for the year 2018-19 and 2019-20 have been settled up to limit of Rs. 2
lacs per year. During the current year since March 1
st
2020, Raksha TPA of the insurer has denied
bills payment of medicines and procedure for treatment of the disease by PGIMER from 2018 and
2019. During the year 2020-21 the test conducted by the PGMIER on 16.03.2020 and 06.04.2020
for the first chemotherapy total bill of Rs.33531/-. Second chemotherapy dated 27.04.2020 bill for
Rs.15742/- and third chemotherapy dated 18.05.2020 bill for Rs.15756/- were submitted. All the
chemotherapy was given at day care center of PGIMER Chandigarh. The Raksha TPA of the insurer
denied all the bills for tests, medicines and chemotherapy by the PGIMER for the reason that
“Patient treated with injection transtuzumab (hormonal treatment-monoclonal antibody-
immunomodulator drug) drug do not require 24 hours hospitalization and not listed under day care
treatment of the policy” and rejected all the bills. The complainant further stated that the
treatment given at PGI for 6-7 hours under the supervision of the doctor’s and nurses would not
cost less than Rs.1 lac per chemotherapy at private hospital where admission would be required
for three days. All the allegations of TPA are baseless and untrue which cannot be accepted. The
complainant sought the intervention of this office for settlement of all bills.
On 16-10-2020, the complaint was forwarded to The Oriental Insurance Co. Ltd. Regional Office,
Chandigarh, for Para-wise comments and submission of a self-contained note about facts of the
case, which was made available to this office on 23-10-2020. As per the SCN, the policy was issued
for the period 01.03.2020 to 28.02.2021. The wife of the insured, Smt. Prem Lata Kalra is a patient
of carcinoma endometrium. Patient was admitted on 06.04.2020, 27.04.2020 and 18.05.2020 at
PGI Chandigarh. In all the above cases, patient was treated with Inj. Trastuzumab (hormonal
treatment- monoclonal antibody- immune modulator drug). This treatment does not require 24
hours hospitalization and also not under the scope of day care treatment as per condition 3.14 of
the policy. Moreover, standalone treatment for immuno modulator for cancer treatment is
permanently excluded from the scope of the policy under policy exclusion 4.21.
The complainant was sent Annexure VI-A for compliance, which reached this office on 02-11-2020.
18) Cause of Complaint:
a) Complainant’s argument: Treatment of patient for cancer through chemotherapy at PGI for 6-7
hours under the supervision of the Doctors and Nurses would not cost less than Rs.1 lac per
chemotherapy at private hospital where admission would be required for three days. The denial of
claim is not justified keeping in view the nature of disease from which his wife is suffering.
b) Insurers’ argument: Patient was treated with Inj. Trastuzumab (hormonal treatment-
monoclonal antibody- immune modulator drug). This treatment does not require 24 hours
hospitalization and also not under the scope of day care treatment as per condition 3.14 of the
policy.
19) Reason for Registration of Complaint: Within the scope of the Insurance Ombudsman Rules, 2017.
20) The following documents were placed for perusal.
a) Complaint to the Company b) Copy of Policy Document
c) Annexure VI-A d) Reply of the Insurance Company
21) Result of Personal hearing with both parties (Observations & Conclusion):
I have gone through the various documents available in file and also considered the submissions
made by complainant and representative of insurance company at the time of on line hearing. It is
observed that complainant’s wife is a known case of carcinoma endometrium and her claims for
treatment at PGI Chandigarh with Injection Transtuzumab have been denied by the insurer under
clause 3.14 of the policy by stating that this treatment does not require 24 hours hospitalization
and not listed under day care of the policy.
It is evident from the claim documents that the patient a known case of carcinoma endometrium
was hospitalized at PGI Chandigarh on 06.04.2020, 27.04.2020 and 18.05.2020 and was treated
with Inj. Transtuzumab. The admission of the patient is related with the treatment of carcinoma
disease for which claims are admissible as per terms and conditions of the policy. The denial of
claim by the insurer for the requirement of minimum 24 hours hospitalization as per clause 3.14 is
not justified as the Cancer Chemotherapy is covered under day care procedure at Sr. No 116 of
Appendix 1 attached with the policy terms and condition. The treatment given to the
complainant’s wife with injection Transtuzumab is a part and parcel of Cancer Chemotherapy.
Therefore, the insurance company is directed to pay the admissible claim amount to the
complainant as per terms and conditions of the policy within 30 days after receipt of award’s copy.
AWARD
Considering the facts & circumstances of the case and the submissions made by both the parties
during the course of hearing, admissible claim amount as per terms and condition of the policy is
hereby awarded to be paid by the insurer to the insured, towards full and final settlement of the
claim.
Hence, the complaint is treated as closed.
Dated at Chandigarh on 21
st
day of January 2021.
D.K. VERMA
INSURANCE OMBUDSMAN
PROCEEDINGS BEFORETHE INSURANCE OMBUDSMAN, CHANDIGARH
(UNDER INSURANCE OMBUDSMAN RULES, 2017)
INSURANCE OMBUDSMAN- Dr. D.K. VERMA
Case of Mr. Rajesh Kumar V/S The United India Insurance Co. Ltd.
COMPLAINT REF. NO: CHD-H-051-2021-0413
1.
Name & Address of the Complainant
Mr. Rajesh Kumar
S/o Sh. Jai Chand, R/o Village- Jhanu, P.O.-
Solan, Tehsil & Distt.- Solan, Himachal Pradesh-
173212
Mobile No.- 9882175597
2.
Policy No:
Type of Policy
Duration of policy/Policy period
5001002819P111086236
Group Health Insurance Policy
01.10.2019 to 30.09.2020
3.
Name of the insured
Name of the policyholder
Mr.Rajesh Kumar/Ms. Jyoti
IBA A/c PNB
4.
Name of the insurer
The United India Insurance Co. Ltd.
5.
Date of Repudiation
29.05.2020
6.
Reason for repudiation
Nursing Home not fulfil Hospital clause
7.
Date of receipt of the Complaint
25-11-2020
8.
Nature of complaint
Nonpayment of claim
9.
Amount of Claim
Rs. 26000/-
10.
Date of Partial Settlement
NA
11.
Amount of relief sought
Rs. 26000/-
12.
Complaint registered under
Rule no: Insurance Ombudsman Rules,
2017
Rule 13 (1)(b) – any partial or total repudiation
of claim by an insurer
13.
Date of hearing/place
22.01.2021/ Chandigarh/Through VC
14.
Representation at the hearing
For the Complainant
Mr.Rajesh Kumar
For the insurer
Ms.Mamta Bansal
15
Complaint how disposed
Dismissed
16
Date of Award/Order
22.01.2021
17) Brief Facts of the Case:
On 25-11-2020, Mr. Rajesh Kumar had filed a complaint vide which he informed that his wife was admitted
in Malan Nursing Home, Solan HP from 09.02.2020 to 12.02.2020 and was gifted with a boy baby. The
entire original bills of around Rs. 26000/- were sent Raksha TPA Chandigarh office on 17.02.2020. Company
asked for doctor’s certificate for bedding facility and the same was submitted to the company. Raksha TPA
rejected his claim stating Malan Nursing Home has submitted 6 bedded certificates so claim is rejected. He
took up the matter with Nursing Home who issued another letter confirming that they have 10 bedded
facility but 4 beds were reserved for COVID patients. He requested Raksha TPA to make independent
investigation to make the objection clear but company has rejected his claim despite of repeated requests.
He requested for settlement of his genuine claim.
On 02-12-2020, the complaint was forwarded to The United India Insurance Co. Ltd. Regional Office,
Chandigarh, for Para-wise comments and submission of a self-contained note about facts of the case,
which was made available to this office on 19.01.2021. The complainant was sent Annexure VI-A for
compliance, which reached this office on 14.12.2020.
As per SCN submitted by insurance company, they have issued a Group Mediclaim policy to IBA-PNB
covering their employees with their dependent members for the period 01.10.2019 to 30.09.2020. Rajesh
Kumar alongwith dependent member Mrs. Jyoti(spouse) and children are included in the above mentioned
policy for S.I. of Rs. 4,00,000/-. Company received claim for patient Mrs. Jyoti hospitalized from 09.02.20 to
12.02.20 in Malan Nursing Home, Solan for claim amount of Rs. 25394/-. It is observed that patient had a
NCD with RMLE at Malan Nursing Home, Solan. The said nursing home is only 6 bedded with O.T. and
labour room as certified by the nursing home. As per clause 2.18 of the policy, the hospital should be either
registered as a hospital with local authorities under the clinical establishments (registration and regulation)
Act 2010 or it should comply with the minimum requirement of having 10 beds in towns having a
population of less than 10 lakhs and at least 15 beds in all other places. This nursing home is neither
registered under the Clinical Establishments Act nor does it comply with the minimum requirement of
having 10 beds. In view of same, the claim was repudiated.
18) Cause of Complaint:
a) Complainant’s argument: Insurance Company has denied genuine claim of her wife on the basis of
wrong grounds without any investigation of actual beds in hospital.
b) Insurers’ argument: Claim is denied on the basis of certificate from treating doctor regarding
number of beds in hospital as per policy terms and conditions.
19) Reason for Registration of Complaint:- within the scope of the Insurance Ombudsman Rules, 2017.
20) The following documents were placed for perusal.
a) Complaint to the Company b) Copy of Policy Document
c) Annexure VI-A d) Reply of the Insurance Company
21) Result of Personal hearing with both parties(Observations & Conclusion)
On perusal of various documents and considering submissions made by both complainant as well as
representative of insurance company it has been observed that maternity claim of Mrs. Jyoti, w/o
complainant hospitalized in Malan nursing home, Solan has been denied by insurance company stating that
the said hospital has 6 bedded indoor facility and does not meet the criteria for a recognized hospital.
Insurance company produced a certificate from the treating doctor confirming that their nursing home is 6
bedded with OT and labour room. Complainant argued that Malan Nursing home has 10 beds and also
submitted a certificate from same doctor stating that the nursing home is 6 bedded with O.T. and labour
room. Doctor clarified that they have 10 beds, out of which four beds have been reserved for Covid -19
patients. During hearing, insurance company also pointed out discrepancies in documents submitted by
complainant. As per discharge summary, patient remained admitted from 09.02.2020(09.15 P.M.) to
12.02.2020 (10.30 P.M.). However, as per bills, date of discharge is 11.02.2020 and not 12.02.2020 as
written in discharge summary. Further, as per complainant and as per bill, date of delivery is 10.02.2020.
But, as per doctor’s undated certificate, Smt. Jyoti delivered at the hospital on 12.02.2020. I have seen the
relevant documents and found insurance company has rightly pointed out the discrepancies. Further, as
per policy conditions, hospital/nursing home should have at least 10 in-patient beds but in this case
treating doctor herself confirmed that they have 6 bedded nursing home. Certificate regarding ten beds
seems after thought as till delivery on 10
th
/11
th
February 2020 there were no designated hospitals for
Covid-19, which became operational only later on. Keeping in view the facts of the case and above
discussion, decision of insurance company to repudiate the above said claim is as per terms and conditions
of the policy, as such does not require any interference. Accordingly the said complaint is hereby dismissed
and no relief is granted.
AWARD
Taking into account the facts & circumstances of the case and the submissions made by both the
parties during the course of hearing held through video conferencing, the said complaint is
hereby dismissed on merits.
Hence, the complaint is treated as closed.
Dated at Chandigarh on 22
nd
day of January, 2021
D.K. VERMA
INSURANCE OMBUDSMAN
PROCEEDINGS BEFORETHE INSURANCE OMBUDSMAN, CHANDIGARH
(UNDER INSURANCE OMBUDSMAN RULES, 2017)
INSURANCE OMBUDSMAN- Dr. D.K. VERMA
Case of Mr. Kalicharan Verma V/S The Oriental Insurance Co. Ltd.
COMPLAINT REF. NO: CHD-H-050-2021-0392
1.
Name & Address of the Complainant
Mr. Kalicharan Verma
R/o H. No.- 422, Sector-6, Hudda, Panipat,
Haryana- 132103
Mobile No.- 9896942198
2.
Policy No:
Type of Policy
Duration of policy/Policy period
261301/48/2020/73
Group Health Insurance
11-04-2019 To 10-04-2020
3.
Name of the insured
Name of the policyholder
Mr. Kalicharan Verma
4.
Name of the insurer
The Oriental Insurance Co. Ltd.
5.
Date of Repudiation
23.10.2020
6.
Reason for repudiation
Not payable as per clause 4.25 of policy
conditions
7.
Date of receipt of the Complaint
11-11-2020
8.
Nature of complaint
Rejection of Mediclaim
9.
Amount of Claim
Rs.6100/- and Rs.14698/-
10.
Date of Partial Settlement
N.A
11.
Amount of relief sought
Rs.6100/-+ Rs.14698/-
12.
Complaint registered under
Rule no: Insurance Ombudsman Rules,
2017
Rule 13 (1)(b) – any partial or total repudiation
of claims by an insurer
13.
Date of hearing/place
22.01.2021/ online
14.
Representation at the hearing
For the Complainant
Mr. Kalicharan Verma
For the insurer
Mr. Anil Relhan
15
Complaint how disposed
Dismissed
16
Date of Award/Order
25.01.2021
17) Brief Facts of the Case:
On 11-11-2020, Mr. Kalicharan Verma had filed a complaint against The Oriental Insurance Co. Ltd
for denial of mediclaim and stated that complainant took OPD treatment for sudden abdominal
pain through R.P Stone Clinic Pvt. Ltd Panipat and from Dr. G.C.Gupta for treatment of illness of
forming Gaddor in side prostate.The insurance company has denied the payment of claim vide
their letter 23.10.2020. The complainant further stated that he is holding the policy of the insurer
since 2005 and paid all the installments. His claim has not been rightly assessed as per policy terms
and conditions and without checking & going through the claimed bill through a paneled and non
paneled hospital. The complainant has sought the intervention of this forum for granting the claim
amount.
On 17-11-2020, the complaint was forwarded to The Oriental Insurance Co. Ltd. Regional Office,
Chandigarh, for Para-wise comments and submission of a self-contained note about facts of the
case, which was made available to this office on 15-12-2020. As per SCN, on scrutiny of the
documents it was observed that the complainant underwent treatment in the Out Patient
Department for pain of abdomen i.e treatment was taken as an outpatient and was never
hospitalized for this aliment.
As per subject policy preamble “Company undertakes that , if during the policy period stated in the
schedule any insured Person(S) shall contract or suffer from any illness/ailment/disease ( herein
after called disease) or sustain any bodily injury through accident ( herein after called Injury) and if
such disease or injury shall require any such Insured Person(S) upon the advice of a duly qualified
Physician/ Medical Specialist / Medical Practitioner ( herein after called Medical Practitioner ) or of
a duly qualified Surgeon( herein after called (SURGEON) to incur expenses on (a) Hospitalization (as
defined herein after) for medical/ surgical treatment at any Nursing Home/ Hospital in India (
Herein after called ‘Hospital) as an inpatient”.
The policy defines under clause 3.21 that “In-Patient means an Insured Person who is admitted to a
Hospital and stay for at least 24 hours for the sole purpose of receiving the treatment for suffered
ailment/ illness / disease/injury/ accident during the currency of the policy”
As such, the claim has been repudiated under policy exclusion 4.25 which states all out patient
treatments including diagnostic , medical or surgical procedures, non- prescribed drugs and
medical supplies, Hormone replacement therapy, sex change or treatment which results from or is
in any way related to sex change.
The complainant was sent Annexure VI-A for compliance, which reached this office on 23-11-2020.
18) Cause of Complaint:
a) Complainant’s argument: Claim has not been rightly assessed as per policy terms and
conditions.
b) Insurer’s argument: Claim is not admissible as per clause 4.25 of the policy terms and
conditions as insured took treatment in the out patient department.
19) Reason for Registration of Complaint: Within the scope of the Insurance Ombudsman Rules, 2017.
20) The following documents were placed for perusal
a) Complaint to the Company b) Copy of Policy Document
c) Annexure VI-A d) Reply of the Insurance Company
21) Result of Personal hearing with both parties (Observations & Conclusion):
On perusal of the various documents available in the file including the copy of the complaint, SCN
of the insurer and submission made by both the complainant and the insurance company during
the online hearing, it has been observed that the medical expenses reimbursement claim of
complainant for treatment of abdominal pain was denied by the insurer as OPD treatment is not
payable as per policy terms and conditions.
The complainant submitted that he is holding the policy of the insurer since 2005 and paid all the
installments. His claim has not been rightly assessed as per policy terms and conditions and
without checking & going through the claimed bills.
The representative of the insurer stated that complainant underwent treatment in the Outpatient
Department for pain of abdomen and was never hospitalized. Therefore claim is not admissible
under policy clause 4.25 as OPD treatment is not covered.
The documents placed on record by the complainant are only the prescriptions, bills, investigation
reports and not the hospitalization papers & discharge summary. The claim papers suggest that
complainant took treatment on OPD basis and was not hospitalized. Since there is no cogent
evidence to establish the factum of hospitalization, claim for OPD treatment is not admissible as
per clause 4.25 of the policy terms and condition. The policy under clause 3.21 defines that “In-
Patient means an Insured Person who is admitted to a Hospital and stay for at least 24 hours for
the sole purpose of receiving the treatment for suffered ailment/ illness / disease/injury/ accident
during the currency of the policy”.
Therefore, the claim denial decision of the insurer is as per policy terms and conditions and does
not warrant any interference. The complainant is dismissed being devoid of merits and no relief is
granted
ORDER
Taking into account the facts & circumstances of the case and the submissions made by both the
parties during the course of video conference hearing, no relief is granted to complainant.
Hence, the complaint is treated as closed.
Dated at Chandigarh on 25
th
day of January 2021
D.K. VERMA
INSURANCE OMBUDSMAN
PROCEEDINGS BEFORETHE INSURANCE OMBUDSMAN, CHANDIGARH
(UNDER INSURANCE OMBUDSMAN RULES, 2017)
INSURANCE OMBUDSMAN- Dr. D.K. VERMA
Case of Mr. Vinil Kapoor V/S The Oriental Insurance Co. Ltd.
COMPLAINT REF. NO: CHD-H-050-2021-0396
1.
Name & Address of the Complainant
Mr. Vinil Kapoor
H. No.- 640, Sector-16 A, First Floor, Faridabad,
Haryana- 121002
2.
Policy No:
Type of Policy
Duration of policy/Policy period
272400/48/2020/10068
Group Health Insurance
12-12-2019 To 11-12-2020
3.
Name of the insured
Name of the policyholder
Mr. Vinil Kapoor
4.
Name of the insurer
The Oriental Insurance Co. Ltd.
5.
Date of Repudiation
13.08.2020
6.
Reason for repudiation
Not payable as per policy clause 3.18
7.
Date of receipt of the Complaint
17-11-2020
8.
Nature of complaint
Rejection of mediclaim
9.
Amount of Claim
Rs.16919/-
10.
Date of Partial Settlement
N.A
11.
Amount of relief sought
Claim Amount
12.
Complaint registered under
Rule no: Insurance Ombudsman Rules,
2017
Rule 13 (1)(b) – any partial or total repudiation
of claims by an insurer
13.
Date of hearing/place
22.01.2021/ Online
14.
Representation at the hearing
For the Complainant
Mr. Vinil Kapoor
For the insurer
Mr. Anil Nagpal
15
Complaint how disposed
Dismissed
16
Date of Award/Order
25.01.2021
17) Brief Facts of the Case:
On 17-11-2020, Mr. Vinil Kapoor had filed a complaint against The Oriental Insurance Co. Ltd for
denial of claim and stated that complainant’s wife got admitted in Faridabad Medical centre for
treatment. The complainant filed reimbursement claim with the insurer and submitted all the
original documents. The claim has been denied by the insurer as the patient had not stayed in the
hospital for 24 hours. It is just short of 54 minutes as per the insurance company, Mediassist TPA,
whereas, the complainant has clear show of the REFERRAL to the upper hospital for further
investigation, Faridabad Medical Centre where the treatment was going on had referred for the
tests and their letter is also attached. The test report of Sarvodya Hospital Faridabad are also
attached which clearly indicated that the patient was referred and tested there. Now the time to
reach and test clearly shows that there was more than 24 hours time for the patient in treatment
and tests. The complainant has sought the intervention of this forum for payment of his claim.
On 19-11-2020, the complaint was forwarded to The Oriental Insurance Co. Ltd. Regional Office,
New Delhi, for Para-wise comments and submission of a self-contained note about facts of the
case, which was made available to this office on 21-12-2020. According to SCN, the complainant is
against the repudiation of claim under policy no. 2272400/48/2020/10068. That during the validity
of the said policy having sum insured of Rs. 500000/-with policy period from 12.10.2019 to
11.10.2020, insurer received the claim for reimbursement of expenses incurred on the treatment
of Mrs. Rupee Kapoor beneficiary under the policy. The claim documents submitted by the insured
(More particularly final bill of hospital) reveal that the beneficiary Mrs. Rupee Kapoor admitted at
Faridabad Medical Centre on 18.06.2020 for medical treatment of Typhoid/Pneumonia at 12.54
P.M and after giving treatment discharged from hospital on 19.06.2020 at 12.00 P.M. Thus insured
/beneficiary have not remained in hospital for more than 24 hours. As per policy condition 3.18,
the claim under the policy is admissible only, if the hospitalization is more than 24 hours. Hence by
invoking condition 3.18, claim is therefore repudiated. The condition inter alia provides as under:
Hospitalization: means admission in a hospital for a minimum period of twenty four (24) in-patient
care consecutive hours except for specified procedures/treatments where such admission could be
for a period of less than 24 consecutive hours.
Thus the repudiation of claim is as per policy terms and conditions.
The complainant was sent Annexure VI-A for compliance, which reached this office on 22-11-2020.
18) Cause of Complaint:
a) Complainant’s argument: The claim decision of the insurer due to less than 24 hours is not
justified.
b) Insurer’s argument: Claim is not admissible as per clause 3.18 of the policy terms and conditions.
19) Reason for Registration of Complaint: Within the scope of the Insurance Ombudsman Rules, 2017.
20) The following documents were placed for perusal.
a) Complaint to the Company b) Copy of Policy Document
c) Annexure VI-A d) Reply of the Insurance Company
21) Result of Personal hearing with both parties (Observations & Conclusion):
On perusal of the various documents available in the file including the copy of the complaint, SCN
of the insurer and submission made by both the complainant and the insurance company during
the online hearing, it has been observed that the medical expenses reimbursement claim for
treatment of complainant’s wife in Faridabad Medical Centre was denied by the insurer under
clause 3.18 of the policy terms and conditions as the patient had not stayed in the hospital for 24
hours.
The complainant submitted that patient’s stay in the hospital is just short of 54 minutes and was
referred for further investigations by the hospital.
The representative of the insurer stated that insured/beneficiary have not remained in hospital for
more than 24 hours. As per policy condition 3.18, the claim under the policy is admissible only, if
the hospitalization is more than 24 hours. Hence by invoking condition 3.18, claim was therefore
repudiated.
As per the refer slip and final hospital bill , the complainant was admitted in the Faridabad Medical
Centre for treatment of Dysentery & Pneumonia on 18.06.2020 at 12.54 P.M and discharged on
19.06.2020 at 12.00 P.M. It is amply clear that the hospitalization of the patient for treatment was
less than 24 hours. The claim denial decision of the insurer on the ground that claim is admissible
only if the hospitalization is more than 24 hours, is as per policy terms and conditions and does
not warrant any interference. Therefore, the complainant is dismissed being devoid of merits and
no relief is granted.
ORDER
Taking into account the facts & circumstances of the case and the submissions made by both the
parties during the course of video conference hearing, no relief is granted to complainant.
Hence, the complaint is treated as closed.
Dated at Chandigarh on 25
th
day of January 2021.
D.K. VERMA
INSURANCE OMBUDSMAN
PROCEEDINGS BEFORETHE INSURANCE OMBUDSMAN, CHANDIGARH
(UNDER INSURANCE OMBUDSMAN RULES, 2017)
INSURANCE OMBUDSMAN- Dr. D.K. VERMA
Case of Mrs. Neeraj Grover V/S Aditya Birla Health Insurance Co. Ltd.
COMPLAINT REF. NO: CHD-H-055-2021-0403
1.
Name & Address of the Complainant
Mrs. Neeraj Grover
W/o Sh. Rajiv Grover, H. No.- 22,
Ajit Nagar, Near Mahesh Nagar, Ambala Cantt,
Ambala, Haryana-0
Mobile No.- 9417629835
2.
Policy No:
GHI19-3618839
Type of Policy
Duration of policy/Policy period
Group Activ Health Policy
10.12.2019 to 09.12.2020
3.
Name of the insured
Name of the policyholder
Mr. Rajiv Grover
Bajaj Finance Limited
4.
Name of the insurer
Aditya Birla Health Insurance Co. Ltd.
5.
Date of Repudiation
25.07.2020
6.
Reason for repudiation
Within waiting period of two years
7.
Date of receipt of the Complaint
11-11-2020
8.
Nature of complaint
Rejection of mediclaim
9.
Amount of Claim
Rs.57000/-
10.
Date of Partial Settlement
-
11.
Amount of relief sought
Claim Amount
12.
Complaint registered under
Rule no: Insurance Ombudsman Rules,
2017
Rule 13 (1)(b) – any partial or total repudiation
of claims by an insurer
13.
Date of hearing/place
22.01.2021/ online
14.
Representation at the hearing
For the Complainant
Mrs. Neeraj Grover
For the insurer
Ms. Manali Shukla
15
Complaint how disposed
Agreement
16
Date of Award/Order
25.01.2021
17) Brief Facts of the Case:
On 11-11-2020, Mrs. Neeraj Grover had filed a complaint against Aditya Birla Health Insurance Co.
Ltd. for non-payment of mediclaim and submitted that her husband Rajiv Grover felt unconscious
on 25.12.2019 and was taken to Saket Hospital Ambala cantt and from CT scan it was diagnosed to
be a case of Brain Hemorrhage. The insured was referred to Fortis hospital Mohali where it was
informed that ESI Scheme is not available in Fortis and it was directed to deposit Rs. 5 lac
immediately for operation. Due to the financial constraints, insured person was taken to Cygnus
Hospital Karnal under ESI Scheme where he was operated upon 26.12.2019 and discharged on
24.01.2020. The insured after respiratory problem was again admitted to Dua Hospital Karnal on
26.01.2020 and discharged on 07.02.2020. Dua hospital was not covered under ESI Scheme,
therefore taking into sympathetic consideration it was allowed to make concessional payment of
Rs.57000/- only.
The complainant while searching his papers it was discovered that he is having some policy and
claim of Rs.57000/- was lodged. In spite of repeated reminders, the claim position was not
informed and finally vide e-mail dated 30.08.2020 it was informed that the claim has been
repudiated due to pre-existing disease of hypertension vide letter dated 25.07.2020. The
complainant further submitted that her husband was only diabetic but never suffered from
hypertension. It has been wrongly assumed presumed by the company that he was suffering from
hypertension at the time of policy. The complainant has sought the intervention of this forum for
payment of his claim.
On 24-11-2020, the complaint was forwarded to Aditya Birla Health Insurance Co. Ltd. Regional
Office, Mumbai, for Para-wise comments and submission of a self-contained note about facts of
the case, which was made available to this office through mail on 07.01.2021. As per SCN, insured
Sh. Rajiv Grover his spouse and daughter are covered under Group Activ Health Policy issued to
Bajaj Finance Limited under the Master Policy No. 61-19- 00015-00-00. The insured members are
covered under the said policy from 10.12.2019 to 09.12.2020. The insured raised a reimbursement
request for the hospitalization of the insured for undergoing treatment for respiration distress
which was rejected initially. It is humbly submitted that the company has reconsidered that claim
and is falling short of few documents to process further and arrive at admissible claim for which
insurance company is getting in touch with the customer to procure the below mentioned
documents;
Claim Form Part A and Part B
Cancelled Cheque of Primary Insured
However, insurance company vide their e-mail dated 08.01.2021 submitted that in the captioned
matter they have contacted the customer for submission of few documents which were not
submitted at the time of reimbursement and these documents are still awaited.
18) The complainant agreed to accept the offer of the insurance company during online hearing on
22.01.2021 that they are ready to pay a claim as per policy terms and conditions under policy no
GHI19-3618839 subject to submission of the required documents as enumerated in their mail to
complainant on 31.12.2020.
19) Keeping view the acceptance of offer, the complaint is closed with a direction to the complainant
to submit the required documents to insurer within 15 days from the receipt of copy of this order.
The insurance company after settling claim shall send a compliance report to this office within 30
days of receipt of this order for information and record.
Dated at Chandigarh on 25
th
day of January 2021
(Dr. D. K. VERMA)
INSURANCE OMBUDSMAN
PROCEEDINGS BEFORETHE INSURANCE OMBUDSMAN, CHANDIGARH
(UNDER INSURANCE OMBUDSMAN RULES, 2017)
INSURANCE OMBUDSMAN- Dr. D.K. VERMA
Case of Mr. Munish Verma V/S Reliance General Insurance Co. Ltd.
COMPLAINT REF. NO: CHD-H-035-2021-0456
1.
Name & Address of the Complainant
Mr. Munish Verma
R/o Ward No.- 14, Green Park Colony, Kathua
Mobile No- 9858250321
2.
Policy No:
Type of Policy
Duration of policy/Policy period
2021831828120000001
J& K Group Mediclaim Policy
3.
Name of the insured
Name of the policyholder
Mr. Munish Verma
Mr. Munish Verma
4.
Name of the insurer
Reliance General Insurance Co. Ltd.
5.
Date of Repudiation
Not Applicable
6.
Reason for repudiation
Not Applicable
7.
Date of receipt of the Complaint
16-12-2020
8.
Nature of complaint
Claim approved but not credited
9.
Amount of Claim
Rs 1.00 lacs
10.
Date of Partial Settlement
22-12-2020 for Rs 79486/-
11.
Amount of relief sought
Rs 1.00 Lacs
12.
Complaint registered under Rule no:
Insurance Ombudsman Rules, 2017
Rule 13 (1)(b) – any partial or total repudiation of
claims by an insurer
13.
Date of hearing/place
Video Conferencing 22-01-2021 / Chandigarh
14.
Representation at the hearing
For the Complainant
Mr. Munish Verma, Complainant
For the insurer
Mr. Dhruv Sharma
15
Complaint how disposed
Dismissed
16
Date of Award/Order
25-01-2021
17) Brief Facts of the Case:
On 16
th
, December 2020, Mr Munish Verma complained to this office that he had registered health claim
no -202190005712 with insurance company. His claim is approved but amount is not credited. His last
query was received by insurance company on 23-02-2019 and his claim was shown approved on 25-08-
2020. He got a reply that “claim approved but pending with Jammu and Kashmir finance/ treasury
department” whenever he wrote email to grievance cell and customer care. On 12-09-2020, he got an
email from customer care that the amount will be credited in bank account in one week but same was not
done. He requested this forum to look into the matter
On 16-12-2020, the complaint was forwarded to Reliance General Insurance Co. Ltd. Regional Office,
Chandigarh, for Para-wise comments and submission of a self-contained note about facts of the case,
which was made available to this office on 21-01-2021.
Insurance company stated in the SCN that the complainant had taken J& K Group Mediclaim Insurance
Policy (This is a tender based policy group health policy) which covers the employees of J&K Govt and the
employees of autonomous bodies under J&K Govt. vide Policy No- 2021831828120000001. The
Complainant is the Govt Teacher and works in Govt. M.S. Kalibari and claim is of Mrs. Ansuya Devi, aged
70yrs, Mother of employee who was admitted in Dayanand Medical College date of admission- 24-11-2018
with diagnosis Obstructive Uropathy due to Urethral Stricture with Hyponatremia in a K/C/O. DM & HTN
underwent Urethral Dilatation and discharged on 30-11-2018. Claim was submitted which was registered
vide claim no- 202190005712 as Reimbursement and documents were submitted on 19-01-2019. Claim
was queried for short fall documents on 25-01-2019, 01-02-2019 and 16-03-2019. On receiving all short fall
documents claim was adjudicated on 05-04-2019 as admissible subject to enrollment and premium receipt
confirmation from Govt of J & K. Despite follow up was done with Govt as the reconciliation process need
to be done at their end. Eventually in December 2020 the company took humanitarian approach giving
benefit of doubt to the claimant and approved the claim on 21-12-2020 and settlement was done on 22-
12-2020. Since 64 VB confirmations was pending hence the claim got delayed without prejudice. The Claim
of of complainant was finally approved and paid vide NEFT No- N357201348702564 dated 22.12.2020, IFSC
Code- SBIN0006897, State Bank of India Amounting Rs 79,486/- (Rs Seventy nine thousand four hundred
eighty six only). There is no deficiency in services on the part of Insurance Company because the claim of
the Insured was processed as per the terms & conditions of the policy, and the amount has been paid to
the complainant. They requested for dismissal of complaint.
The complainant was sent Annexure VI-A for compliance, which reached this office on 24-12-2020.
18) Cause of Complaint:
a) Complainant’s argument: Complainant stated that insurance company has delayed his claim
payment on flimsy grounds. He requested for payment of his claim.
b) Insurers’ argument: Insurance Company stated that they have paid the claim as per terms and
condition of policy. The claim payment was delayed since it was a policy of J& K government
employees confirmation with regard to enrollment and premium receipt was required from Govt of J
& K. But same was not confirmed and due to which the payment was delayed. They requested for the
dismissal of the complaint.
19) Reason for Registration of Complaint:- within the scope of the Insurance Ombudsman Rules, 2017.
20) The following documents were placed for perusal.
a) Complaint to the Company b) Copy of Policy Document
c) Annexure VI-A d) Reply of the Insurance Company
21) Result of Video Conferencing with both parties(Observations & Conclusion):
On examination of various documents available in file including the copy of complaint, SCN filed by
insurance company and submissions made by both complainant and insurance company at the time of
video conferencing, it is seen that there is no dispute that payment of complainant’s mother claim for
hospitalization has been made on 22-12-2020 and claim was shown approved on 25-08-2020 but shown
pending with Jammu and Kashmir finance/ treasury department by either party. It is seen that this was a
tender based policy group health policy of J& K government employees. In the instant case it is seen that
any payment of claim is based only upon verification of enrollment of member and premium receipt
confirmation from J& K Government. It is seen that inspite of claim approval by insurance company they
couldn’t make the payment since it showed pending on the part of Jammu and Kashmir finance/ treasury
department. These above circumstances were not in the control of insurance company and they can’t be
held solely responsible for delayed payment. Since complainant has received the payment of his claim no
further action is required at this end. The complaint is accordingly dismissed.
AWARD
Taking into account the facts & circumstances of the case and the submissions made by both
the parties during the course of video conferencing, the said complaint is hereby dismissed on
merits.
Hence, the complaint is treated as closed.
Dated at Chandigarh on 25
th
day of January 2021.
D.K. VERMA
INSURANCE OMBUDSMAN
PROCEEDINGS BEFORE
THE INSURANCE OMBUDSMAN, STATE OF TAMIL NADU & PUDUCHERRY
(UNDER RULE NO: 16/17 OF THE INSURANCE OMBUDSMAN RULES, 2017)
OMBUDSMAN – Shri M Vasantha Krishna
Case of Ms A Amutha Vs United India Insurance Company Limited
COMPLAINT REF: NO: CHN-H-051-2021-0294
Award No: IO/CHN/A/HI/0112/2020-2021
1.
Name & Address of the
Complainant
Ms A Amutha,
12/8, Gurumoorthy Garden Street,
Perambur,Chennai - 600 011.
2.
Policy No.
Type of Policy
Duration of Policy/Policy Period
Sum Insured (SI)
5001002819P111085480
Group Health Policy
01.10.2019 to 30.09.2020
INR 4 lakhs
3.
Name of the Insured
Name of the Policyholder/Proposer
Ms A Amutha
Indian Banks Association (IBA) A/c Bank
of Maharashtra
4.
Name of the Insurer
United India Insurance Company Limited
5.
Date of repudiation of the claim
21.05.2020(through the Bank)
6.
Reason for repudiation
The treatment undergone does not
warrant hospitalization
7.
Date of receipt of the complaint
07.08.2020
8.
Nature of complaint
Repudiation of the claim
9.
Date of receipt of Consent
(Annexure VI A)
12.11.2020
10.
Amount of Claim
INR 85,956
11.
Amount paid by Insurer, if any
NIL
12.
Amount of Monetary Loss (as per
Annexure VI A)
INR 85,956
13.
Amount of Relief sought (as per
Annexure VI A)
INR 85,956
14. a.
Date of request for Self-contained
Note (SCN)
29.10.2020
14. b.
Date of receipt of SCN
10.12.2020
15.
Complaint registered under
Rule No. 13(1) (b) of the Insurance
Ombudsman Rules, 2017
16.
Date of Hearing/Place
By Video Conferencing (VC) on
21.12.2020
17.
Representation at the hearing
a) For the Complainant
Ms A Amutha
b) For the Insurer
Mr K P Divyaraj and Dr. Padmanabh
Shirodkar
18.
Disposal of Complaint
By Award
19.
Date of Award/Order
08.01.2021
20. Brief Facts of the Case:
The complainant as an employee of Bank of Maharashtra is covered under the Group
Health Policy issued to the Bank, a member of IBA, by the Respondent Insurer (RI) for a
Sum Insured (SI) of INR 4 lakh.
As per Discharge Summary, the complainant was admitted in Prime Indian Hospital,
Chennai on 09.03.2020 with the chief complaints of headache, giddiness, on and off pain
in the upper abdomen, nausea, loose stools, vomiting and history of fever since 1 week.
She was diagnosed as a case of vertigo, cervical spondylosis and gall bladder polyp and
was treated with conservative medical management with IV fluids antibiotics, analgesics,
vitamins, antiemetics, antacids and other supportive drugs. She was discharged on
14.03.2020.
The treating doctor has vide his certificate dated 17.03.2020 stated that she was admitted
with the above complaints and was advised Laparoscopic Cholecystectomy but she
decided to undergo the surgery only after improvement in her general condition.
On 11.03.2020, the request for cashless treatment facility made by the hospital on her
behalf was approved by the Third-party Administrator (TPA) of the RI for the provisional
diagnosis of AGE (acute gastroenteritis) with vertigo and cervical spondylosis for an
amount of INR 37,000 and the same was withdrawn at the time of her discharge on the
ground that “as per claim documents received it is observed that the treatment given to
the patient does not support the need for hospitalization”. Her reimbursement claim for the
hospitalization expenditure was also rejected on the same grounds.
She represented to the RI for a review of the decision to reject the claim but her
representation did not receive any positive response. She has therefore approached the
Forum for redressal.
21 (a) Complainant’s Submission:
The complainant submits that during the treatment and further investigation the
doctors observed some polyps in her gall bladder which if unattended, would turn
to abnormal polyps. Therefore, she was advised to undergo surgery for the same.
She is also suffering from cervical disc bulge C3 - C6 spine.
When she was about to be discharged, she got a call from the TPA stating that
the claim is rejected as the treatment she underwent does not require any
hospitalization and could have been managed on out-patient (OPD) basis.
She also submits that her admission in the hospital was on the advice of the
treating doctor only.
She contacted the Customer Care of the TPA prior to discharge when she was
informed that her claim is under process. She was supposed to be discharged on
13.03.2020 but since the decision by the TPA was delayed, she cleared the
hospital bills on her own and could get discharged only on 14.03.2020.
Post-discharge, she submitted a reimbursement claim which was also denied by
the TPA stating that “the treatment given to the patient does not support the need
for hospitalization hence the claim is repudiated”.
She is of the view that the TPA made a false promise that her claim is under
process and that they have considered only the cervical spondylosis and have
ignored all the other ailments for which she took treatment during hospitalization.
She has therefore requested the Forum to do the needful and provide her
necessary relief.
21 (b) Insurer’s Submission:
The RI have submitted their SCN dated 10.12.2020.
The complainant was diagnosed with vertigo with cervical spondylosis and gall
bladder polyp.
The CT scan of the complainant was suggestive of cervical spine C3 - C4, C4 - C5
and C5 – C6 disc posterior bulge and the USG - abdomen showed gall bladder
polyp. She was managed conservatively with IV analgesic and other supportive
treatment.
The treatment given does not support the need for hospitalization and can be given
on an OPD basis.
The claim was reviewed again and it was opined that the hospitalization was
primarily for the purpose of investigation and evaluation.
The claim has been processed as per policy terms and conditions and as per
exclusion clause 4.7 which reads as “Charges incurred at Hospital or Nursing
Home primarily for diagnosis x-ray or Laboratory examinations or other diagnostic
studies not consistent with or incidental to the diagnosis and treatment of positive
existence of presence of any ailment, sickness or injury, for which confinement is
required at a Hospital/Nursing Home unless recommended by the attending
doctor”, the claim has been repudiated.
22. Reason for Registration of the Complaint:
The complaint is registered under Rule No. 13(1) (b) of the Insurance Ombudsman Rules,
2017, which reads as “Any partial or total repudiation of claims by the Life Insurer, General
Insurer or the Health Insurer”.
23. Documents placed before the Forum:
Written Complaint dated 25.06.2020 to the Insurance Ombudsman
Claim repudiation letter of the RI undated
Consent (Annexure VI A) submitted by the Complainant
Self-contained Note (SCN) of the RI dated 10.12.2020
Policy copy, terms and conditions
Discharge summary/Reports/Bills of Prime Indian Hospital, Chennai
Claim form dated 18.03.2020
Cashless authorisation letter dated 11.03.2020 of the TPA
Mail correspondence by the complainant with the Insurer and TPA
Consultation note dated 09.03.2020 of Dr. Kodeeswaran
Certificate of Dr. Kodeeswaran dated 17.03.2020
24. Result of hearing (Observations & Conclusion)
Given the prevailing situation due to Covid 19 virus, the hearing was conducted by VC
on 21.12.2020, with the consent and participation of both parties. Ms A Amutha, the
complainant, Mr K P Divyaraj, insurer’s representative and Dr Padmanab Shirodkar,
representative of the TPA attended the hearing.
There is a delay of one month in the submission of the SCN by the insurer. The Forum
records its displeasure over late submission of SCN and advises the insurer to be
prompt in complying with the Forum’s requirements in future.
During the hearing, the complainant submitted that during March 2020 she got
admitted in a private hospital with the complaints of fever, spinal pain, indigestion,
chest pain and vomiting. It was an emergency admission and she stayed in the
hospital for five days. Initially, the TPA gave approval for cashless and in the final
stage, they cancelled the approval. The reason stated for rejecting the approval was
that her condition was not that serious to be admitted in the hospital.
The Forum enquired whether the complainant has undergone laparoscopic
Cholecystectomy as advised by the treating doctor to which she responded that the
surgery was not an immediate necessity. She also confirmed that the surgery was
recommended immediately on her admission in the hospital. However, the discharge
summary is silent regarding the recommendation made to the complainant to undergo
the surgery and the same is mentioned only in the doctor’s certificate dated
17.03.2020.
On the other hand, the representative of the TPA argued that her admission was for
the surgical procedure and since the surgery was deferred, the cashless approval was
cancelled.
The Forum questioned the TPA as to why the cashless approval was given for only
INR 37,000 when the request was for INR 60,000. The TPA responded that approval
was given as per PPN Tariff. The Forum directed the RI/TPA to submit the Tariff.
The RI vide their mail dated 06.01.2020 have forwarded the PPN tariff with the treating
hospital which confirms that the hospital is one of the network hospitals.
It is observed that as per cashless approval given by the TPA, the proposed line of
treatment was conservative management for AGE with vertigo and cervical
spondylosis for 5 days and there is no mention of any surgery. The Forum is therefore
of the view that the cashless approval was given and liability for the claim admitted by
the TPA knowing very well that the treatment to be given was conservative and not on
the premise of any surgery to be performed. Hence, there is no justification for the
contention of the RI that the cashless approval was withdrawn as no surgery was
performed. Hence, the RI is liable to pay the claim.
The Forum is also of the opinion that the rejection of the claim under clause no. 4.7 of
the policy was not entirely appropriate since the diagnostic tests undergone by the
complainant established the positive existence of cervical spondylosis and gall bladder
polyp and her hospital admission was apparently on the recommendation of the
treating doctor. It is observed that the policy does not contain any clause specifically
excluding unwarranted hospitalisation.
25. The attention of the Insurer is hereby invited to the following provisions of the
Insurance Ombudsman Rules, 2017:
AWARD
Taking into account the facts & circumstances of the case and the submissions
made by both the parties, the Forum hereby directs the respondent insurer to
settle the claim of the complainant for INR 85,956 subject to the terms and
conditions of the Policy along with interest as provided under Rule 17(7) of the
Insurance Ombudsman Rules, 2017.
Thus, the complaint is allowed.
a) According to Rule 17(6) of the Insurance Ombudsman Rules, 2017, the insurer
shall comply with the award within thirty days of the receipt of the award and
intimate compliance of the same to the Ombudsman.
b) According to Rule 17(7) of the Insurance Ombudsman Rules, 2017, the
complainant shall be entitled to such interest at a rate per annum as specified in the
regulations, framed under the Insurance Regulatory and Development Authority of
India Act, 1999, from the date the claim ought to have been settled under the
regulations, till the date of payment of the amount awarded by the Ombudsman.
c) According to Rule 17(8) of the Insurance Ombudsman Rules, 2017, the award of
Insurance Ombudsman shall be binding on the insurers.
Dated at Chennai on this 8
th
day of January 2021.
(M Vasantha Krishna)
INSURANCE OMBUDSMAN
FOR THE STATE OF TAMIL NADU AND PUDUCHERRY
PROCEEDINGS BEFORE
THE INSURANCE OMBUDSMAN, STATE OF TAMIL NADU & PUDUCHERRY
(UNDER RULE NO: 16/17 OF THE INSURANCE OMBUDSMAN RULES, 2017)
OMBUDSMAN – Shri M Vasantha Krishna
Case of Mrs Malathi Venkittaraman Vs United India Insurance Company Limited
COMPLAINT REF: NO: CHN-H-051-2021-0301
Award No: IO/CHN/A/HI/0118/2020-2021
1.
Name & Address of the Complainant
Mrs Malathi Venkittaraman,
Flat No. 1 AB, Sixth Block, Kences Enclave,
No.1, Ramakrishna Street, T. Nagar, Chennai
– 600 017.
2.
Policy Nos.
Type of Policy
Duration of Policy/Policy Period
Sum Insured (SI)
5001002819P111085480 /
1630002819P102019104
IBA Policy / Group Health Policy
01.10.2019 to 30.09.2020; 02.04.2019 to
01.04.2020
INR 3 lakhs / INR 3 lakhs
3.
Name of the Insured
Name of the Policyholder/Proposer
Mrs. Malathi Venkittaraman
IBA Policy A/c Bank of Maharashtra;
Bank of Maharashtra
4.
Name of the Insurer
United India Insurance Company Limited
20. Brief Facts of the Case:
The complainant who is an employee of Bank of Maharashtra is covered under the Group
Health Policy issued by the respondent insurer (RI) to Bank of Maharashtra for a Sum
Insured (SI) of INR 3 lakhs. She is also covered under another policy issued to the Bank
as per arrangement made by Indian Banks Association, again for a SI of INR 3 lakhs.
As per Discharge Summary, the complainant was admitted in SRM Institutes for Medical
Science (SIMS) on 21.10.2019 with the diagnosis of severe calcific aortic stenosis and
underwent aortic valve replacement using 21 MM St. Jude Mechanical Valve on
22.10.2019 and was discharged on 29.10.2019.
Out of the total expenditure of INR 5,31,199, a sum of INR 3 lakhs was approved on a
cashless basis under the IBA Policy and a further settlement of INR 1,04,340 was effected
from the buffer available under the same policy, by MD India, the Third-Party
Administrator (TPA) of the RI. She submitted a claim of INR 1,26,859 for the remaining
amount with HITPA, the TPA of the RI for the other policy availed by the Bank. However,
5.
Date of Short Settlement of the claim
02.01.2020
6.
Reason for Short settlement
Settled as per PPN Tariff
7.
Date of receipt of the Complaint
14.10.2020
8.
Nature of Complaint
Short settlement of the claim
9.
Date of receipt of Consent (Annexure
VI A)
17.11.2020
10.
Amount of Claim
INR 5,31,199
11.
Amount paid by Insurer, if any
INR 4,04,340
12.
Amount of Monetary Loss (as per
Annexure VI A)
INR 1,26,859
13.
Amount of Relief sought (as per
Annexure VI A)
INR 1,26,859
14. a.
Date of request for Self-contained
Note (SCN)
03.11.2020
14. b.
Date of receipt of SCN
07.12.2020
15.
Complaint registered under
Rule No. 13(1) (b) of the Insurance
Ombudsman Rules, 2017
16.
Date of Hearing/Place
By Video Conferencing (VC) on 11.01.2021
17.
Representation at the hearing
c) For the Complainant
Mr Venkittaraman (Husband of the
complainant)
d) For the Insurer
Mr. Anil Ghodeswar/Mr. Vikas Jaganath
Mane/Ms Anitha Alwarswamy
18.
Disposal of Complaint
By Award
19.
Date of Award/Order
21.01.2021
the claim was rejected under clause no 2.25 on the ground that the maximum amount
payable as per the Preferred Provider Network (PPN) tariff has already been paid under
the other policy (the IBA policy) and hence no further amount is payable.
Aggrieved by the response, the complainant represented to the Grievance Cell of the RI to
reconsider the rejection of the claim for INR 1,26,859. The RI informed her vide their e-
mail dated 13.10.2020 that the settlement already made was in order as per the
Reasonable and Customary Charges (R&CC) clause no. 2.35 of the policy which reads as
below.
Reasonable charges means the charges for services or supplies, which are the standard
charges for the specific provider and consistent with the prevailing charges in the
geographical area for identical or similar services, taking into account the nature of the
illness/injury involved.
It was also claimed by the RI that as per Clause 2.25 of the policy, the claim is admissible
only as per the PPN package rate which is INR 2,59,950 in the present case. An amount
of INR 4,04,340 has already been paid under the other policy (the IBA Policy – Policy no.
5001002819P111085480) and the balance of expenditure cannot be claimed under any
other policy. Therefore, the complainant has approached this Forum for relief.
21 (a) Complainant’s Submission:
The complainant submits that her claim for the residual amount of INR 1,26,859
was rejected by HITPA on the ground that as per the agreement entered into with
the hospital in 2014, the PPN package for the procedure undergone by her is INR
1,90,000 plus an amount of INR 69,950 towards the cost of the implant,
aggregating to INR 2,59,950. Since more than this amount has already been paid
to her under the other policy, they took the stand that she is not entitled to any
further amount.
The complainant has expressed the view that medical expenses have increased
three-fold and hence the package rates of 2014 do not hold good in 2019. She
has claimed that expenditure of INR 5.30 incurred by her is very reasonable and
she is entitled to full indemnity.
Her enquiries with other hospitals in Chennai whom she visited for a second
opinion revealed that they charge in the range of INR 5 lakhs to INR 7 lakhs for
the treatment she underwent.
She has therefore requested the Forum to intervene and direct the RI to settle
her claim.
21 (b) Insurer’s Submission:
The RI have stated vide their SCN that the claim was repudiated under clause no.
2.25 reading as below.
Network provider means hospitals or health care provider enlisted by an insurer or
by TPA and insurer together to provide medical services to an insured on payment
by a cashless facility. The list of network hospitals is maintained by and available
with the TPA and the same is subject to amendment from time to time. Preferred
Provider Network means a network of hospitals which have agreed to a cashless
packaged pricing for certain procedures for the insured person. The list is available
with the company/TPA and subject to amendment from time to time.
Reimbursement of expenses incurred in PPN for the procedures (as listed under
PPN packages) shall be subject to the rates applicable to PPN package pricing.
22. Reason for Registration of Complaint:
The complaint is registered under Rule No. 13(1) (b) of the Insurance Ombudsman Rules,
2017, which deals with “Any partial or total repudiation of claims by the Life Insurer,
General Insurer or the Health Insurer”.
23. Documents placed before the Forum.
Written Complaint dated 14.10.2020 to the Insurance Ombudsman
Request for cashless hospitalisation dated 17.10.2019
Cashless Authorisation letter of MD India TPA dated 29.10.2019
Claim form dated 07.11.2019
Claim settlement letter of the RI dated 02.01.2020
Claim repudiation letter of the RI dated 28.08.2020
Complainant’s representation dated 03.08.2020 to the Insurer
Insurer’s response dated 13.10.2020 to the Complainant
Consent (Annexure VI A) submitted by the Complainant
Self-contained Note (SCN) of Insurer
Copy of Policies (2 nos.) with terms and conditions
Discharge summary/Bills of SIMS Hospital, Chennai
Other correspondence of the complainant with the Insurer and TPA
24. Result of hearing (Observations & Conclusion)
Given the prevailing situation due to Covid 19 pandemic, the hearing was
conducted by VC on 11.01.2021, with the consent and participation of both the
parties. The complainant authorised her husband Mr Venkittaraman to represent
her vide her mail dated 11.01.2021 and he participated in the hearing. Mr Anil
Ghodeswar and Mr Vikas Jagannath Mane, representatives of the TPA and Mrs
Anita Alwarswamy, insurer’s representative attended the hearing.
There is a delay of one month in submission of the SCN by the insurer. This Forum
records its displeasure over the late submission of SCN and advises the insurer to
be prompt in complying with the Forum’s requirements in future.
During the hearing, the complainant’s representative reiterated the arguments put
forth by the complainant in her written submissions to the Forum. Similarly, the
representatives of the RI and the TPA restated their stand as was articulated in
their correspondence with the complainant and the SCN.
The Forum questioned the RI and the TPA how there exist two different PPN
packages for the same procedure with the same hospital. The question also arises
how the hospital has billed the complainant much more than the agreed tariff. If the
RI and the TPA have failed to enforce the PPN agreement with the hospital by
ensuring latter’s adherence to the tariff, the complainant cannot be denied the
indemnity of the amount incurred by her.
The RI repudiated the claim by invoking Policy Clause 2.25 whereas they also
invoked clause no. 2.35 (R&CC clause) in their response to the complainant’s
representation. But the invocation of clause 2.35 is not supported with the standard
charges of the treating hospital or the comparable charges of the other hospitals in
the neighbourhood as specified in the clause. The Forum is also of the considered
opinion that PPN tariff being a negotiated tariff cannot be a benchmark for
Reasonable & Customary Charges.
Strangely, the RI reverted to clause no. 2.25 – PPN Network in their defence, in the
SCN submitted to the Forum. This shows that they were not clear about the
grounds of repudiation.
The Forum directed the RI to submit the details of both the PPN packages with the
hospital for the procedure in question. They have not submitted the same so far.
The Forum observes that as per clause no. 1.2.1 of Policy
no.1630002819P102019104 the complainant is entitled to reimbursement of the
actual expenditure on major surgery, subject to a maximum of 70% of the SI.
Hence, her maximum eligibility for the present surgery (a cardiac surgery) which is
major surgery as defined in the clause is INR 2,10,000. The amount claimed her is
INR 1,26,859, well within the said limit.
The RI should process the claim of the complainant for INR 5,31,199 following the
open billing method and pay the amount due to her after making the following
deductions.
a) Non-medical charges
b) Non-payable charges
c) Amount of INR 4,04,340 paid under the other policy.
25. The attention of the insurer is hereby invited to the following provisions of the
Insurance Ombudsman Rules, 2017:
d) According to Rule 17(6) of the Insurance Ombudsman Rules, 2017, the insurer
shall comply with the award within thirty days of the receipt of the award and
intimate compliance of the same to the Ombudsman.
e) According to Rule 17(7) of the Insurance Ombudsman Rules, 2017, the
complainant shall be entitled to such interest at a rate per annum as specified in the
regulations, framed under the Insurance Regulatory and Development Authority of
India Act, 1999, from the date the claim ought to have been settled under the
regulations, till the date of payment of the amount awarded by the Ombudsman.
f) According to Rule 17(8) of the Insurance Ombudsman Rules, 2017, the award of
Insurance Ombudsman shall be binding on the insurers.
AWARD
Taking into account the facts & circumstances of the case and the submissions
made by both the parties during the course of hearing, the Forum hereby directs
the respondent insurer to settle the claim of the complainant for INR 1,26,859
under Policy no. 1630002819P102019104 subject to the terms and conditions
thereof, along with interest as provided under Rule 17(7) of the Insurance
Ombudsman Rules, 2017.
Thus the complaint is Allowed.
Dated at Chennai on this 21
st
day of January 2021.
(M Vasantha Krishna)
INSURANCE OMBUDSMAN
FOR THE STATE OF TAMIL NADU AND PUDUCHERRY
PROCEEDINGS OF THE INSURANCE OMBUDSMAN, DELHI
(Under Rule 13 r/w 16 of the Insurance Ombudsman Rules, 2017)
Ombudsman: Shri Sudhir Krishna
Case of Samarendra Kanungo versus United IndiaInsurance Company Ltd.
Complaint Ref. No.: DEL-H-051-2021-0217
1.
Name & Address of the Complainant
ShriSamarendra Kanungo,
c/o Hari Om Tokas, H. No. 687/A, 1
st
Floor,
Near Canara Bank, Munirka, New Delhi-110067
2.
Policy No.
Type of Policy
Policy term/policy period
0703002818P112034910
Health Insurance-Group Policy
01.12.2018 to 30.11.2019
3.
Name of the insured
Name of the policy holder
Debendranath Kanungo
Wipro Limited, for Samarendra Kanungo
4.
Name of insurer
United India Insurance Company Ltd.
5.
Date of repudiation
05.12.2019
6.
Reason for grievance
Non-settlement of Mediclaim
7.
Date of receipt of the complaint
17.08.2020
8.
Nature of complaint
Non-settlement of Mediclaim
9.
Amount of claim
Rs.23391/-
10.
Date of partial settlement
N.A.
11.
Amount of partial settlement
N.A.
12.
Amount of relief sought
Rs.23391/-
13.
Complaint registered under Rule No. of
the Insurance Ombudsman Rules 2017
Rule 13(1)(b)- Any Partial or total repudiation of claims by
an Insurer
14.
Date of hearing
29.01.2021
Place of hearing
Delhi,Online Video Conferencing via Cisco WebEx App
15.
Representation at the hearing
a) For the Complainant
Shri Samarendra Kanungo, the Complainant
b) For the Insurer
Smt. Vimala Waran, Senior Divisional Manager, DO-3,
Bengaluru
16.
Date of Award/Order
Recommendation under Rule 16/ 29.01.2021
17. Brief Facts of the Case: Shri. Samarendra Kanungo (hereinafter referred to as the
Complainant) has filed this complaint against the decision of the United India Insurance
Company Ltd. (hereinafter referred to as the Insurers or the Respondent Insurance Company)
allegingnon-settlement of Mediclaim.
18. Cause of Complaint:
a) Complainant's Argument:The Complainant has stated that on 14
th
November, 2019 his father was
found unconscious in his bed room, having difficulty in talking and even unable to walk due to
numbness in the body. He was taken to the Hospital and was prescribed CT scan and other tests. MRI
of his brain could not be done due to the pacemaker placed on his heart and after tests, observations
by the doctor; he was discharged on the next day i.e. 15
th
November, 2019. He opted for cashless
facility but the same was denied by the TPA on the ground that the admission was for evaluation
purpose. He approached the Grievance Cell also but his claim was not settled.
b) Insurer's Argument: The Insurance Company, vide Self Contained Note dated 08.01.2021, have
stated that the patient was a known case of hypertension, Post-PPI-Chronic Kidney disease, and
was admitted at Care Hospital on 14.11.2019 with complaints of voice slurred-early morning, not
able to lift limbs which improved within 30 minutes, no history of loss of conscious, fever.
Medical management was done and patient was discharged on 15.11.2019. Insured submitted a
claim for Rs.23391/-. During hospitalization stay, there was no active line of treatment was taken.
Hence the claim was denied under clause no.4.11 which states: “Charges incurred at Hospital or
Nursing home primarily for diagnosis, x-ray or laboratory examination or other diagnostic studies
not consistent with or incidental to the diagnosis and treatment of positive existence of presence
of any ailment, sickness or injury, for which confinement is required at a Hospital/Nursing
Home.”
19. Reason for registration of Complaint:Non-settlement of Mediclaim.
20. The following documents were placed for perusal:
a) Copy of policy.
b) Copy of GRO Letter, discharge summary, bills, cashless denial, rejection letter.
c) SCN of the Insurer along with enclosures.
21. Result of hearing with the parties (Observations and Conclusion):
Case called. Parties are present and recall their arguments as noted in Para 18 above.
At this stage, the Insurers offer to settle the claim for a sum of Rs. 15823, in full and final
settlement. The Complainant accepts this offer. Thus an agreement of conciliation could be arrived
at between the Complainant and the Insurers, which I consider as fair and reasonable for both the
parties.
Award
The complaint is disposed off in terms of the agreement of conciliation arrived at between the
Complainant and the Insurers. Accordingly, the the Insurers shall settle the claim for a sum of
Rs. 15823, in full and final settlement of the subject claim.
Parties should implement this agreement within 30 days.
(Sudhir Krishna)
Insurance Ombudsman, Delhi
29
th
January 2021
PROCEEDINGS BEFORE
THE INSURANCE OMBUDSMAN, STATES OF A.P., TELANGANA & YANAM
(Under Rule 16(1)/17 of The Insurance Ombudsman Rules, 2017)
Ombudsman - Shri I. Suresh Babu
Case between: Mrs. UPPULURI SRIBALA………………The Complainant
Vs
M/s HDFC ERGO Health Insurance Co. Ltd…………The Respondent
Complaint Ref. No. I.O.(HYD).H .018.2021.0236
Award No.: I.O.(HYD)/A/HI/ 0123/2020-21
1.
Name & address of the
complainant
Mrs. Uppuluri Sribala
H.No. 3-60, Street #6B, Hanuman Nagar,
Dilsukh Nagar,Hyderabad
Telengana State- 500 060
(Cell No. 98499-30034)
2.
Policy No./Collection No.
Type of Policy
Duration of Policy/Policy
period
120100/12586/2020/A017521/PE01986625
Group assurance health plan
01.02.2020 to 31.01.2021
3.
Name of the insured
Name of the Policyholder
Mrs. U Sribala a/c Mr. U G K Sastry
M/s Canara Bank
4.
Name of the insurer
M/s HDFC ERGO Health Insurance Co. Ltd.
5.
Date of Repudiation
14.09.2020
6.
Reason for repudiation
Treatment does not require hospitalization.
7.
Date of receipt of the
Complaint
10.12.2020
8.
Nature of complaint
Rejection of Covid -19 claim
9.
Amount of Claim
Rs. 1,20,000/-
10.
Date of Partial Settlement
----
11.
Amount of Relief sought
Rs. 1,20,000/-
12.
Complaint registered
under
Rule No.13.1 (b) of Ins.
Ombudsman
Rules, 2017
Rule 13.1 (b) – any partial or total
repudiation of claims by the Life
insurer, General Insurer or the
Health insurer
13.
Date of hearing/place
06.01.2021, online at Hyderabad
14.
Representation at the
hearing
a) For the complainant
Mr.U G K Sastry spouse of
Smt.U.Sribala
b) For the insurer
Mr.Sachin Varma
17) Brief Facts of the Case:
The complainant’s husband had purchased an annual health insurance policy through the
intermediary M/s Canara Bank to cover the hospitalization expense of his wife. On 11.07.2020,
she was admitted In Yashoda Hospitals with chief complaints of fever from 2 days, cough, mild
and generalized weakness. She was tested COVID-19 RT PCR Positive and was put under
medication before being discharged on 17.07.2020. The respondent company to whom her
hospitalization claim was submitted had rejected it. Since representation given to their Grievance
department too had not yielded a favorable outcome, she had therefore approached this Forum
to seek justice.
18) Cause of Complaint: Repudiation of claim made against the medical
Insurance policy.
a) Complainant’s argument:
The complainant’s husband had stated that the hospital had refused to
admit her on cashless basis until an advance amount was deposited with
the hospital. Since the time available was limited, the respondent could
not be contacted and she had to be admitted since he was worried about
the ill effects of the virus. He had lamented that the reason given for
rejection of her claim was unfair because no patient would like to get
isolated in an isolation ward of a hospital just for pleasure. The treating
15.
Complaint how disposed
Allowed
16.
Date of Order/Award
06.01.2021
doctor of the hospital alone was competent enough to assess the health
condition of the patient so as to decide if she were to be admitted or not.
b) Insurer’s argument:
Self contained note was submitted by the respondent by mail on
05/01/2020. On perusal of the claim documents, it was noted that the
complainant was hospitalized from 11.7.2020 to 17.07.2020 for Covid-19.
On the day before admission HRCT chest report dated 10/07/2020
showed patient was normal. However, the Discharge summary showed
the insured was diagnosed with Pneumonia. As diagnosis of Pneumonia
was made only after chest examination or x-ray, it was felt that further
investigation and proof was required. In the final bill under heading
“Infection Control Consumable” Rs.52,500/- charged did not show proper
breakup by the hospital. The discharge summary of the hospital
mentioned IV antibiotics was given to patient but in final bills there was
no mention of IV antibiotics. The insured was asked to provide with
necessary proof regarding Pneumonia, break up details of infection
control consumables and bills pertaining to IV antibiotics used to enable
them process the claim. Therefore, the claim could not be considered as
it fell outside the terms and conditions of the policy.
19) Reason for Registration of Complaint:
The insurer rejected the claim preferred by the complainant. As the
complaint falls under Rule 13.1(b) of Insurance Ombudsman Rules, 2017,
it was registered.
20) The following copies of documents were placed for perusal:
a. Policy copy
b. Discharge summary
c. Rejection letter
d. Correspondence with insurer
e. Self contained note with enclosures.
21) Result of the personal hearing with both the parties:
Pursuant to the notices given by this Forum both parties attended the
online hearing at Hyderabad on 06.01.2021.
The complainant’s spouse attended the hearing. He informed that both
of them were attacked with Covid-19 and got hospitalized in Yashoda
Hospital and their cashless claim was denied. His claim was paid by the
insurer after a lot of hurdle and answering to queries while the claim
pertaining to his wife was rejected on the ground that no active line of
treatment was given to her except oral medication and that it did not
require hospitalization. He was at a loss to understand why claim
pertaining to one person was paid and denied for the other under the
same policy.
The Respondent insurer stated that on further verification of claim
documents they now require breakup for Infection control consumables
charged in the final hospital bill amounting to Rs.52,500/- and questioned
why antibiotics used did not find place in the final bill. They also
expressed their doubt how pneumonia could not be detected in CT scan
taken one day prior to hospitalization but get diagnosed as bilateral
pneumonia by the hospital as seen in the discharge summary.
The Forum questioned the respondent insurer whether Yashoda Hospital
was a Network hospital, to which it was answered as “Yes”. The Forum
observed that when the hospital was a network hospital and cashless
facility being denied for Covid-19 patients, it was the duty of Insurer and
the Third party administrator to contact the hospital for clarification. The
complainant cannot be harassed for submission of breakup details for
consumables and antibiotics in the bills paid by the complainant. When a
patient is admitted into a hospital, they rely completely on the attending
doctor who advices him for admission as well as on the evaluation of the
test reports like covid-19 report /CT scan etc. When claim is rejected on a
particular ground the respondent insurer must stick to their stand taken.
Fresh reasons cannot be put forth after rejection of the claim. IRDAI has
also been informing vide their circulars from time to time to settle Covid-
19 cases hassle free. In the instant case the complaint is detected with
Covid-19, she is 64 years old K/C/O DM, hospitalized as per doctors
advice based on her health condition & co morbidity, what benefits will
the insured get if he was charged more or less for consumables or
antibiotics when the entire bill was paid out of their pocket. In what
capacity can a patient explain why one scan report is different to that of
another and how can claim of one person be paid and denied for the
other when both are covered under the same policy and for the same
treatment? This shows careless attitude on the part of the respondent
insurer who are shifting their responsibility onto their customers in times
of pandemic distress. The Forum therefore directs the respondent insurer
to collect all the necessary details from their Network hospital through
their TPA and settle the claim in the similar line as paid to her spouse
immediately as justice delayed is justice denied.
A W A R D
Taking into account the facts & circumstances of the case and the
submissions made by both the parties during the course of the hearing
and the information/documents placed on record, the insurer is directed
to settle the claim as per policy terms & conditions and subject to
Ombudsman Rule 17 (7).
The complaint is Allowed.
22) The attention of the Insurer is hereby invited to the following provisions of Insurance
Ombudsman Rules, 2017:
a) According to Rule 17(6), the insurer shall comply with the award within 30 days of the receipt of
the award and intimate compliance to the same to the Ombudsman.
b) According to Rule 17(7), the complainant shall be entitled to such interest at a rate per annum
as specified in the regulations, framed under the Insurance Regulatory & Development
Authority of India Act from the date the claim ought to have been settled under the Regulations
till the date of payment of the amount awarded by the Ombudsman.
c) According to Rule 17 (8), the award of Insurance Ombudsman shall be binding on the Insurers.
Dated at Hyderabad on the 6
th
day of January , 2021.
( I. SURESH BABU )
OMBUDSMAN
FOR THE STATES OF A.P.,
TELANGANA AND YANAM CITY
PROCEEDINGS BEFORE
THE INSURANCE OMBUDSMAN, STATES OF A.P., TELANGANA & YANAM
(Under Rule 16(1)/17 of The Insurance Ombudsman Rules, 2017)
Ombudsman - Shri I. Suresh Babu
Case between: Mr.A.SIVARAMA SARMA………………The Complainant
Vs
M/s The New India Insurance Co. Ltd…………The Respondent
Complaint Ref. No. I.O.(HYD).H .049.2021.0241
Award No.: I.O.(HYD)/A/GI/ 0125 /2020-21
1.
Name & address of the
complainant
Mr. A.Siva Rama Sarma
I Floor, Jeevan Bhagya Building, Zonal Office,
Saifabad, HYDERABAD, Telangana State.
(Cell No.80089 87903)
2.
Policy No./Collection No.
Type of Policy
Duration of Policy/Policy
period
120700/34/19/04/00000001
Group medical insurance policy for LIC
Employees
01.04.2019 to 31.03.2020
3.
Name of the insured
Name of the Policyholder
Mrs.P Varija, W/o.Mr.A,Siva Rama Sarma
M/s.L I C of India
4.
Name of the insurer
M/s The New India Insurance Co. Ltd.
5.
Date of Repudiation
Not mentioned
6.
Reason for repudiation
Hospitalization not required
7.
Date of receipt of the
Complaint
15.12.2020
8.
Nature of complaint
Claim pertaining to Group Medical
17) Brief Facts of the Case:
The Complainant and his family were covered under the Group Mediclaim Insurance Policy
purchased by their employer M/s.LIC of India from the Respondent Company. On 11.1.2020 his
spouse was admitted to KIMS Hospitals with chief complaints of Melena from 6 months. She was
diagnosed with iron deficiency anemia, Crohn’s Disease, Azoran induced/UGI Bleed. She
underwent blood transfusions and was finally discharged in a stable condition on 13/01/2020. A
claim was made with the TPA of respondent M/s.MD India for a total amount of Rs.94,000/-.
Since there was no response from the TPA and representation made by him to the respondent
company also was not attended to, he had finally approached this Forum to seek justice.
18) Cause of Complaint: Non settlement of claim made against the Group
Medical Insurance policy.
insurance policy
9.
Amount of Claim
Rs. 94000/-
10.
Date of Partial Settlement
----
11.
Amount of Relief sought
Rs. 94,000/-
12.
Complaint registered
under
Rule No.13.1 (b) of Ins.
Ombudsman
Rules, 2017
Rule 13.1 (b) – any partial or total
repudiation of claims by the Life
insurer, General Insurer or the
Health insurer
13.
Date of hearing/place
31.12.2020
14.
Representation at the
hearing
a) For the complainant
Mr.A.Siva Rama Sharma
b) For the insurer
Mr.P.S.Sai Kumar
15.
Complaint how disposed
Award
16.
Date of Order/Award
7/01/2021
a) Complainant’s argument:
The complainant had submitted that his wife had been a Crohn’s patient
since the year 2005 for which she had undergone 2 major surgeries, in
the years 2005 & 2014. On 11.1.2020 she was admitted to KIMS Hospital
since her Hemoglobin levels fell down drastically below the normal range.
Once after her discharge from Hospital her claim bills were submitted to
the TPA of respondent who had acknowledged the receipt of the same by
way of text SMS with an assurance to process her claim within 7 days.
However, there was no response from their end and owing to the current
COVID 19 Pandemic he too had waited for some more time before
reaching out to the customer care centre of TPA to know about the status
of his wife’s hospitalization claim. Reminder mails were sent to them and
since the TPA did not respond to any of his mails, he had therefore
represented his matter to the Grievance department of the respondent
company by sending an e-mail on 09/11/2020 and also by registered post
on 11.11,2020. Thereafter, he had sent another e-mail on 03.12.2020 but
did not receive any reply from the respondent too. Annoyed with their
callous attitude, he had approached this Forum with a question as to the
reason behind the non settlement of her claim despite the fact that she
was admitted to a reputed hospital on the recommendations of a
specialist to undergo an emergency treatment. He had also pointed out
that non settlement of the claim had defeated the purpose for enrolling
in the mediclaim scheme offered by respondent.
b) Insurer’s argument:
The Respondent had submitted their SCN on 30/12/2020. They had
discussed the past history of the insured and stated that the nature of
treatment is mainly for conducting investigations for which
hospitalization was not required. They have also stated that the anemia is
related to her existing Crohn’s disease which is a Genetic Disorder and
not payable under Policy F Clause- Exclusions Point XV(a) Genetic
disorders. They have also stated that the charges incurred at Hospital
primarily diagnosis, X Ray, Lab. Examinations which are not consistent
with or incidental to the diagnosis and treatment of positive existence or
presence of any illness for which confinement is not required at a
Hospital. Hence the claim is correctly repudiated as per terms and
conditions of the policy.
19) Reason for Registration of Complaint:
The insurer rejected the claim preferred by the complainant. As the
complaint falls under Rule 13.1(b) of Insurance Ombudsman Rules, 2017,
it was registered.
20) The following copies of documents were placed for perusal:
a. Policy copy
b. Discharge summary
c. In Patient Bill
d. Pathological reports and Bills
e. SCN
21) Result of the personal hearing with both the parties:
Pursuant to the notices given by this Forum both parties attended the On Line Hearing on
31/12/2020 from their respective places and submitted their arguments in support of their case.
During the Hearing, the complainant had stated that his wife, Mrs .P.Varija, who is insured under
the Group Mediclaim policy was admitted in the KIMS Hospitals, Hyderabad on 11.01.2020, basing
on the advice of the Consulting Doctor, Dr.Sethu Babu,M;D. D.H. She was treated for Iron
Deficiency anemia, Crohn’s Disease, Azoran Induced/UGI Bleed with chief complaint of Melen-6
and discharged on 13.01.2020. The complainant submitted the documents to the TPA for
reimbursement of his claim under the Group Medical Policy. In spite of his several reminders his
claim was not settled by the TPA/Insurer. Hence he has approached the Forum for justice.
The Respondent stated that the insured person has taken treatment towards Iron deficiency
anemia which was caused due to Crohn’s disease which is a Genetic Disorder. Hence the claim
was repudiated basing on the Policy Exclusion No. F xv.(a) Genetic Disorders. They have also
stated that the Insured person has joined only for evaluation purpose, for which confinement in
hospital is not required.
Having heard the arguments and the submissions made by both the parties, the Forum has gone
through policy exclusion mentioned by the Respondent and quote here for brevity. The Policy
Exclusion of F. xv.(a) GENETIC DISORDERS states: ”However treatment for Thalessima,
Haemophilia, Sickle Cell Anemia, Hemolytic Anemia, myeloma, etc. requiring hospitalization to be
covered with a pre and post hospitalization of 30 & 60 days (both as in patient &OPD) is covered
subject to maximum of 75% of Floater Sum Insured of the Family”. Thus the exclusion the
Respondent mentioned for repudiation is in fact recommends for settlement of the claim upto
75% of the Floater Sum insured. Since the complainant is said to be covered for Rs.50,00,000/-
Family Floater Sum Insured his claim falls within the limits of the referred exclusion.
With regard to the other cause of rejection i.e. treatment is not consistent with or incidental to
the diagnosis or positive existence or presence of any illness, this Forum opines that the
Respondent is contradicting their own statements. On the one hand the Respondent has
admitted that the treatment relates to the Crohn’s disease and rejected the claim revoking the
policy exclusion. On the other hand they are stating that the hospital stay is only for evaluation
purpose and hospitalization is not required. Since both the statements are contradictory the
Forum rejects the causes stated for rejection of the claim. It is also noted that the subject policy is
a Group Medical Policy and all the Pre-existing diseases are covered. It is to be noted that the
insured person is known case of Crohn’s disease and the treatment taken is related and relevant
to the said ailment. She was admitted on the advice of a Qualified Medical Practitioner Dr.Sethu
Babu, Gastro Enterologist, and the treatment is in consistent with and relating to the diagnosis
and the claim is admissible under the policy. Under the above circumstances, the rejection of the
claim is found to be unsustainable.
A W A R D
Taking into account the facts & circumstances of the case and the
submissions made by both the parties during the course of the On Line
Hearing and the information/documents placed on record, the insurer is
directed to settle the claim as per the terms and conditions of policy
along with the interest from the date of the filing of last relevant
documents by the insured till the date of payment of the claim as per
Regulations 16.1.(ii) of IDAI(Protection of Policy Holders’ Interests)
Regulations, 2017.
Hence the complaint is allowed.
22) The attention of the Insurer is hereby invited to the following provisions of Insurance
Ombudsman Rules, 2017:
d) According to Rule 17(6), the insurer shall comply with the award within 30 days of the receipt of
the award and intimate compliance to the same to the Ombudsman.
e) According to Rule 17(7), the complainant shall be entitled to such interest at a rate per annum
as specified in the regulations, framed under the Insurance Regulatory & Development
Authority of India Act from the date the claim ought to have been settled under the Regulations
till the date of payment of the amount awarded by the Ombudsman.
f) According to Rule 17 (8), the award of Insurance Ombudsman shall be binding on the Insurers.
Dated at Hyderabad on the 7
th
day of January,2021.
( I. SURESH BABU )
OMBUDSMAN FOR THE
STATES OF ANDHRA PRADESH
TELANGANA AND YANAM CITY
PROCEEDINGS BEFORE
THE INSURANCE OMBUDSMAN, STATES OF A.P., TELANGANA & YANAM
(Under Rule 16(1)/17 of The Insurance Ombudsman Rules, 2017)
Ombudsman - Shri I. Suresh Babu
Case between: Mrs. S SIRAJ BEGUM………………The Complainant
Vs
M/s The United India Insurance Co. Ltd…………The Respondent
Complaint Ref. No. I.O.(HYD).H .051.2021.0242
Award No.: I.O.(HYD)/A/HI/ 0129 /2020-21
1.
Name & address of the
complainant
Mrs. S Siraj Begum
Manager, APG Bank, Kadapa,
Flat #307, Keerthy Residency, Co-operative
Colony,Kadapa ,Andhra Pradesh- 516 001
(Cell No. 94403-96727)
2.
Policy No./Collection No.
Type of Policy
Duration of Policy/Policy
period
0509002819P102101491
Group health insurance policy
1 year
3.
Name of the insured
Name of the Policyholder
Mrs. S Siraaj Begum
M/s AP Grammena Vikas Bank
4.
Name of the insurer
M/s The United India Insurance Co. Ltd.
5.
Date of Repudiation
Not mentioned
6.
Reason for repudiation
Not mentioned
7.
Date of receipt of the
Complaint
27.11.2020
17) Brief Facts of the Case:
The complainant had purchased two health insurance policies, one from M/s HDFC ERGO Health
insurer and the second from the respondent company. During the period of insurance, she was
admitted to STAR Hospitals on 02.02.2020 with complaints of bilateral knee pain. She was
diagnosed with bilateral Osteoarthritis to her knees for which she had undergone bilateral total
knee replacement. She was discharged from the hospital on 07.02.2020. She had filed a claim with
both the insurers of which the insurer M/s HDFC ERGO had settled her claim as per the policy
terms and conditions for an amount of Rs. 3 Lakhs as against the sum insured of Rs. 5 Lakhs. The
claim made with the respondent for her balance hospitalization treatment cost and the post
hospitalization expenses were settled by respondent only for an amount of Rs. 39,581/-. Not
satisfied with the partial settlement of her claim, she had represented her matter with the
8.
Nature of complaint
Claim pertaining to medical insurance
policy
9.
Amount of Claim
Rs. 2,21,302/-
10.
Date of Partial Settlement
10.09.2020
11.
Amount of Relief sought
Rs. 1,81,721/-
12.
Complaint registered
under
Rule No.13.1 (b) of Ins.
Ombudsman
Rules, 2017
Rule 13.1 (b) – any partial or total
repudiation of claims by the Life
insurer, General Insurer or the
Health insurer
13.
Date of hearing/place
01.01.2021, online at Hyderabad
14.
Representation at the
hearing
a) For the complainant
Self
b) For the insurer
Mr.Kurmaiah, SDM
15.
Complaint how disposed
Allowed
16.
Date of Order/Award
11.01.2021
respondent but could not evoke any response from them which therefore had led her to approach
this Forum to seek justice.
18) Cause of Complaint: Partial payment of hospitalization claim made
against the group medical Insurance policy.
a) Complainant’s argument:
The complainant had submitted that the total package cost for the
surgery was Rs. 4,86,000/- of which the total treatment bill
amount was Rs. 4,85,155/-. The first insurer, namely, M/s HDFC ERGO
Health insurance Co. Ltd. had paid an amount of Rs. 3,00,000/-. For the
balance amount of Rs. 1,85,155/- along with an amount of Rs. 19,626/-
incurred towards her pre-hospitalization expense she claimed with the
TPA of the respondent company. Subsequently, she had also filed a
supplementary claim pertaining to her post- hospitalization for an
amount of Rs. 16,521/- thus amounting to Rs. 2,21,302/-. However, the
respondent company had paid her a meager amount of Rs. 39,581/-. Her
efforts to impress upon the respondent to reopen her claim file and to
settle her balance claim amount was futile.
b) Insurer’s argument:
No self contained note was submitted by the respondent.
19) Reason for Registration of Complaint:
The insurer rejected the claim preferred by the complainant. As the
complaint falls under Rule 13.1(b) of Insurance Ombudsman Rules, 2017,
it was registered.
20) The following copies of documents were placed for perusal:
a. Policy copy
b. Discharge summary
c. Rejection letter
d. Correspondence with insurer
21) Result of the personal hearing with both the parties:
Pursuant to the notices given by this Forum both parties attended the
online hearing at Hyderabad on 01.01.2021.
The complainant stated she was a bank manger and was covered under
Bank group insurance policy with the respondent insurer for a sum
insured of Rs.4 lakhs and she also had another policy for a sum insured of
Rs.5 Lakhs with HDFC ergo insurance company. She underwent both knee
transplant surgery and the total hospitalization expense came to
Rs.4,85,155/- out of which she received cashless settlement of Rs.3 Lakhs
from HDFC Ergo health insurance. She has claimed the balance amount of
Rs.1,85,155/- plus pre and post hospitalization bills amounting to Rs.
19,626/- & Rs. 16,521/- respectively from the respondent insurer.
However her claim was partially settled for Rs.39,581/-. She was at a loss
to understand as no formal letter of explanation was given. The amount
was deposited by way of NEFT into her account.
The Respondent Insurer stated that GIPSA companies have entered into
agreements with hospitals wherein fixed package rates are agreed upon
for various treatments. For knee transplant of both knees the agreed
package rate was Rs.3 Lakhs. Since this package rate was fixed and all the
insurance companies have to abide by the said amount, no extra amount
over and above the package rate was permissible as per policy terms and
conditions. When the forum sought for submission of Group policy terms
and conditions issued to the complainant having a mention of the said
condition, the respondent insurer requested time till 11.01.2021 which
was granted. The respondent insurer submitted copy of group policy
terms & conditions vide mail dated 11.01.2021.
The Forum observed that Group Health Insurance Policy 2.25 condition
on which the insurer is relying upon to deny the claim, reads “ Network
Provider: it means hospitals or health care providers enlisted by an
insurer or by a TPA & Insurer together to provide medical services to an
insured on payment by a cashless facility. The list of Network hospitals is
maintained by and available with the TPA and the same is subject to
amendment from time to time. Preferred Provider Network means a
network of hospitals which have agreed to a cashless package pricing for
certain procedures for the insured person. The list is available with the
company/ TPA and subject to amendment from time to time.
Reimbursement of expenses in PPN for the procedures (as listed under
PPN package) shall be subject to the rates applicable to PPN package
pricing.” Another policy condition no.5.10 which reads “ if
at the time when a claim arises under the Policy, there is in existence any
other insurance taken by the insured to indemnity the treatment cost,
the insured person shall have the right to require a settlement of the
claim in terms of any of his policies. If the amount to be claimed exceeds
the sum insured, under a single policy, after considering deductibles or
co.pay, the insured person shall have the right to choose the insurers by
whom the claim is to be settled. In such cases the company shall not be
liable to pay or contribute more than its ratable proportion if loss,
liability, compensation cost or expenses”. “Note: the insured person must
disclose such other insurance at the time of making the claim.”
As per the above which cites two conditions, it is obvious that the second
clause 5.10 is in contravention to 2.25 conditions. Whereas condition
2.25 states all procedures are subject to PPN package rates, Condition
5.10 gives the insured the right to claim from multiple polices. From
IRDAI Health Insurance Regulations on Multiple policies, it is observed
that in case of multiple policies which provide fixed benefits, on
occurrence of the insured event in accordance with the terms and
conditions of the policies, each insurer shall make the claim payments
independent of payments received under other similar policies. IRDAI
circular no.IRDAI/HLT/REG/GR/005/01/2017 dated 11.01.2017 has
further clarified that the policy holder having multiple policies shall also
have the right to prefer claims from other policy/policies for the amounts
disallowed under the earlier chosen policy even if the sum insured is not
exhausted.
In the instant case the complainant was partially settled for the pre and
post hospitalization amount as under:
Balance claimed under second policy: Rs.1,85,155
Pre and post hospitalization paid: Rs. 39,581
Balance unpaid: Rs. 1,45,574
Where an insured has policies from more than one insurer to cover the
same risk on indemnity basis, the insured shall only be indemnified the
hospitalization costs incurred in accordance with the terms and
conditions of the chosen policy. GIPSA stands for General Insurers Public
Sector Association. 4 public sector insurers have created an association
and empanelled hospitals for fixed closed packages for specific surgeries.
Agreements are entered by TPA’s with hospitals for uniformity of rates
and this does not restrict the insured from claiming for the spillover
amounts duly incurred and paid by him from other available Non- GIPSA
insurers. Conditions no 5.10 clearly supports the insured from claiming
under multiple policies subject to the actual hospitalization expense. In
case the insured first approached the RI, then they are right in following
GIPSA rates even if multiple policies are with the same insurer. However,
in the instant case it is not so that the complainant has got multiple
policies with the same respondent insurer to enable them to restrict their
claim as per GIPSA PPN package. Hence, this Forum directs the
respondent insurer to accept the claim and settle the balance amount
due as per IRDAI health guidelines and subject to policy co pay and
deductibles for major surgeries.
A W A R D
Taking into account the facts & circumstances of the case and the
submissions made by both the parties during the course of the hearing
and the information/documents placed on record, the insurer is directed
to accept and settle the balance claim amount as per terms and
conditions of the Policy.
The complaint is Allowed.
22) The attention of the Insurer is hereby invited to the following provisions of Insurance
Ombudsman Rules, 2017:
g) According to Rule 17(6), the insurer shall comply with the award within 30 days of the receipt of
the award and intimate compliance to the same to the Ombudsman.
h) According to Rule 17(7), the complainant shall be entitled to such interest at a rate per annum
as specified in the regulations, framed under the Insurance Regulatory & Development
Authority of India Act from the date the claim ought to have been settled under the Regulations
till the date of payment of the amount awarded by the Ombudsman.
i) According to Rule 17 (8), the award of Insurance Ombudsman shall be binding on the Insurers.
Dated at Hyderabad on the 11 th day of January , 2020.
( I. SURESH BABU )
OMBUDSMAN
FOR THE STATES OF A.P.,
TELANGANA AND YANAM CITY
PROCEEDINGS BEFORE
THE INSURANCE OMBUDSMAN, STATES OF A.P., TELANGANA & YANAM
(Under Rule 16(1)/17 of The Insurance Ombudsman Rules, 2017)
Ombudsman - Shri I. Suresh Babu
Case between: Mr. KOMPELLA YAGNA NARAYANA SOMAYAJULU ……The Complainant
Vs
M/s Manipal Cigna Health Insurance Co. Ltd…………The Respondent
Complaint Ref. No. I.O.(HYD).H .053.2021.0235
Award No.: I.O.(HYD)/A/HI/ 0133 /2020-21
1.
Name & address of the
complainant
Mr. Yagna Narayana Somayajulu Kompella
D. No. 17-2-1/1h, Flat #303, Anjanadri
Apartments,Beside Chaitanya Hospital,
Rajamahendravaram,East Godavari District
Andhra Pradesh- 533 105
(Cell No. 94400-16757)
2.
Policy No./Collection No.
Type of Policy
Duration of Policy/Policy
period
100200000001/03/00
Family Floater- Master Group insurance
31.05.2020 to 30.05.2021
3.
Name of the insured
Name of the Policyholder
Mrs. Kompella Manikyavalli A/cMr. Yagna
Narayana Somayajulu Kompella
M/s Andhra Bank
4.
Name of the insurer
M/s Magna Cigna Health Insurance Co. Ltd.
5.
Date of Repudiation
05.07.2020
6.
Reason for repudiation
Claim falls within the waiting period of the
17) Brief Facts of the Case:
The complainant had renewed his medical insurance policy which was purchased from the
respondent for a further period of 1 year effective from 31.05.2020. During this period of
insurance, his wife was admitted to Tapani Hospital on 17.06.2020 where she underwent
Functional endoscopic sinus surgery for her right nasal sinusitis and was discharged the following
day. Her hospitalization claim filed with respondent for reimbursement was denied on grounds of
her illness falling within the waiting period of the policy. Representation given to respondent to
review the claim based upon a clarification given by complainant too had yielded no result and
hence he had approached this Forum for a favorable resolution to his case.
policy
7.
Date of receipt of the
Complaint
14.12.2020
8.
Nature of complaint
Claim pertaining to group medical
insurance policy
9.
Amount of Claim
Rs. 53,112/-
10.
Date of Partial Settlement
----
11.
Amount of Relief sought
Rs. 53,112/-
12.
Complaint registered
under
Rule No.13.1 (b) of Ins.
Ombudsman
Rules, 2017
Rule 13.1 (b) – any partial or total
repudiation of claims by the Life
insurer, General Insurer or the
Health insurer
13.
Date of hearing/place
28.12.2020, online at Hyderabad
14.
Representation at the
hearing
a) For the complainant
Self
b) For the insurer
Mr.Jaswinder Singh Shekawat
15.
Complaint how disposed
Allowed
16.
Date of Order/Award
13.01.2021
18) Cause of Complaint: Repudiation of claim made against the medical
Insurance policy.
a) Complainant’s argument:
The complainant had stated that he had purchased the insurance policy
from the respondent on 08.06.2018 with a total cover of Rs. 10 Lakhs. On
30.05.2019, he had received a telephonic call from the respondent’s
official that his policy was being renewed on that day for administrative
convenience in view of the merger of his company. Subsequently he had
received a fresh policy of insurance which was effective from 31.05.2019.
On enquiring with the company’s official as to why he was issued a fresh
policy, he was told that the reason could have been because of the
merger of insurance company. Thereafter, the same policy was renewed
for a further period of 1 year on 31.05.2020 at sum insured of Rs. 10
Lakhs. His wife had to undergo a micro surgery for her acute right nasal
sinusitis at Tapani Hospitals on 16.06.2020 for which her hospitalization
claim was filed with the respondent on 25.06.2020 which was duly
acknowledged on 03.07.2020. However, when the claim was repudiated
on 05.07.2020, he had approached the respondent with his argument
that the first inception of the policy was on 08.06.2018 and as per that
policy, his wife had completed the waiting period of 24 months as on her
date of admission to hospital. The first year renewal policy which was
wrongly issued by the respondent with the commencement date of risk
as 31.05.2019 was done so without his intervention and also without
obtaining a fresh mandate from him to debit from his bank account. In
response to his appeal, the respondent’s official from the customer care
department had apologized to him for the mistake committed by them
and informed him that the claim made was under reconsideration.
Despite waiting for a sufficient period of time and after corresponding
with the respondent on several occasions with a request to settle the
claim, he was asked to display patience and cooperate with them in order
to settle the claim. However no response was forth coming even after
waiting for a considerable period of time. Hence, he had pleaded before
this Forum to mediate between him and the respondent and to direct the
respondent to endorse the policy with the date of first inception of
insurance from 08.06.2018 instead of 31.05.2019 so that the claim of his
wife shall become admissible.
b) Insurer’s argument:
Self contained note was submitted by the respondent by mail on
24.12.2020. They had issued a Master Group insurance policy to Andhra
Bank under where the complaint was enrolled as customer. On
11.01.2018 the complainant had submitted a proposal form through their
master policy holder (Andhra Bank) for purchasing health insurance. On
the basis of the information furnished in the proposal form, the
complainant was covered for a sum insured of Rs.10 Lakhs effective from
08.06.2018 to 07.06.2019. Further in the year 2019, ie., on 31.05.2019
the complainant had submitted a fresh proposal form through the master
policy holder (Andhra bank ) on the basis of which they had issued a
policy commencing from 31.05.2019 to 30.05.2020. Subsequently this
policy was renewed for a further period of one year effective from
31.05.2020 to 30.05.2021 treating this as first renewal.During this first
renewal period of insurance, the claimant had filed a claim for
Rs.53,112/- towards his wife’s hospitalization in Tapani Hospitals where
she was admitted from 17.06.2020 to 18.06.2020 to undergo functional
endoscopic sinus surgery for her Right nasal sinusitis. The Clause No. IV.4
(h) which reads as “A waiting period since beginning of cover under the
first policy, specified in the policy schedule/ certificate of insurance shall
apply to the treatment, of the following, whether medical or surgical for
all medical expenses along with their complications on treatment
towards: h) chronic supportive Otitis Media(CSOM), deviated nasal
septum, sinusitis and related disorders, surgery on tonsils/ adenoids,
tympanoplasty and any other benign ear, nose and throat disorder or
surgery” , was invoked. Since the commencement of the first insurance
policy 31.05.2019, the waiting period of 24 months did not elapse on the
date of admission of the patient and therefore, the claim was rightly
repudiated as per the terms and conditions of the policy issued to the
customer.
19) Reason for Registration of Complaint:
The insurer rejected the claim preferred by the complainant. As the
complaint falls under Rule 13.1(b) of Insurance Ombudsman Rules, 2017,
it was registered.
20) The following copies of documents were placed for perusal:
a. Policy copy
b. Discharge summary
c. Rejection letter
d. Correspondence with insurer
e. Self contained note with enclosures.
21) Result of the personal hearing with both the parties:
Pursuant to the notices given by this Forum both parties attended the
online hearing at Hyderabad on 28.12.2020.
The complainant stated that he had taken the first annual Mediclaim
policy whose effective date was 08/06/2018 as account holder of Andhra
Bank. In May 2019 he received a call from the insurance agent to renew
his policy in view of merger of Andhra Bank with Union Bank of India.
However, he had received the policy whose effective renewal date was
from 31.05.2019 instead of 08/06/2019. When he had filed a claim
towards his wife’s hospitalization, her claim was rejected citing 24
months waiting period. He had contended that neither he had given a
fresh proposal form for issuance of a new policy nor he had given a
cheque as consent to underwrite it as a fresh policy. Hence, the question
of waiting period of 24 months did not arise in this case since first policy
commencement was from 08.06.2019.
The Respondent insurer had stated the old policy premium was auto
debited whereas the policy issued for the period 2019-20 was not auto
debited and therefore the complainant was aware at the time of making
payment as regards the Fresh policy terms and conditions.
He has also stated that they had issued the policy only after obtaining a
fresh proposal form from the insured.
The Forum questioned the respondent insurer as to whether the Pre
voice insurance call was recorded, the terms & conditions of the fresh
policy and fresh waiting period clause was explained to him. The
Respondent insurer was not able to provide any evidence of the same. In
the meantime, the complainant had objected to the respondent official’s
statement that he had signed the proposal form for the policy period
2019-20 which was never given to him. He had also stated that he had
not given any letter to terminate his previous insurance policy effective
from 08.06.2018 to 07.06.2019 so as to permit the insurer to treat the
policy issued from 31.05.2019 to 30.05.2020 as a fresh policy. He was
given to understand that the second policy which was advanced to
31.05.2019 instead of 08.06. 2019 was on account of merger of Andhra
bank with Union bank of India and does not impact the terms and
conditions of the existing policy.
The Forum observes that first policy effective from 08.06.2018 to
07.06.2019 contains enrolment form which is not signed by the proposer.
However, an amount of Rs.17, 497/- is shown as debited towards
payment of first premium for availing this health insurance policy.
Similarly the policy stated to have been issued after bank merger
commenced from 31.05.2019 to 30.05.2020 for which like amount of
Rs.17, 497/- was debited on 31.05.2019; the enrolment form for issuance
of this policy too does not contain the proposer’s signature. Further the
enrolment form contains the name of Andhra Bank and not Union Bank
as the Master Policy holder. This policy is renewed again from 31.05.2020
to 31.05.2021 where the premium is debited from the credit card of the
insured and issued in the name of Union Bank of India (Master policy
holder). The respondent insurer has failed to obtain the consent of the
proposer in the proposal form. They did not change the name of the
master policy holder and have also failed to refund the premium amount
under the previous policy for the unexpired period. It is therefore evident
that the policy issued during first renewal cannot be treated as fresh
policy because the name of the master policy holder remains the same
and also no option was given to the insured to either continue with the
old policy or to accept the fresh policy.
The respondent insurer has therefore come forward vide their mail dated
28.12.2020 at 2.59 PM to admit the claim and settle it as per policy terms
and conditions. Hence this Forum directs the insurer to settle the claim
duly endorsing all the continuity benefits accrued thereon.
A W A R D
Taking into account the facts & circumstances of the case and the
submissions made by both the parties during the course of the personal
hearing and the information/documents placed on record, the insurer is
directed to settle the claim as per policy terms & conditions duly
endorsing all the continuity benefits.
The complaint is Allowed.
22) The attention of the Insurer is hereby invited to the following provisions of Insurance
Ombudsman Rules, 2017:
j) According to Rule 17(6), the insurer shall comply with the award within 30 days of the receipt of
the award and intimate compliance to the same to the Ombudsman.
k) According to Rule 17(7), the complainant shall be entitled to such interest at a rate per annum
as specified in the regulations, framed under the Insurance Regulatory & Development
Authority of India Act from the date the claim ought to have been settled under the Regulations
till the date of payment of the amount awarded by the Ombudsman.
l) According to Rule 17 (8), the award of Insurance Ombudsman shall be binding on the Insurers.
Dated at Hyderabad on the 13 th day of January , 2021.
( I. SURESH BABU )
OMBUDSMAN
FOR THE STATES OF A.P.,
TELANGANA AND YANAM CITY
` PROCEEDINGS BEFORE
THE INSURANCE OMBUDSMAN, STATES OF A.P., TELANGANA & YANAM
(Under Rule 16(1)/17 of The Insurance Ombudsman Rules, 2017)
Ombudsman - Shri I. Suresh Babu
Case between: SRI A SATYANARAYANA………………The Complainant
Vs
M/s HDFC ERGO General Insurance Co. Ltd…………The Respondent
Complaint Ref. No. I.O.(HYD).H .018.2021.0275
Award No.: I.O.(HYD)/A/GI/ 0137 /2020-21
1.
Name & address of the
complainant
Mr. Anna Bathula Satyanarayana
Door No. 15/7/1/3C, Balaji Nagar, Near SMN
Flyover,
Ramakrishna Rao Peta,
Kakinada, Andhra Pradesh- 533 001
(Cell No. 99498-55578)
2.
Policy No./Collection No.
Type of Policy
Duration of Policy/Policy
period
140100/12586/2020/A017016/PEO1952121
Individual/ Group assurance health plan
01.01.2020 to 31.12.2020
3.
Name of the insured
Name of the Policyholder
Mr Annabathula Satyanarayana
M/s Equitas Small Finance Bank Limited
4.
Name of the insurer
M/s HDFC ERGO General Insurance Co. Ltd.
5.
Date of Repudiation
23.11.2020
6.
Reason for repudiation
Claim falls within the waiting period clause
of policy
7.
Date of receipt of the
Complaint
06.01.2021
8.
Nature of complaint
Claim pertaining to medical insurance
policy
9.
Amount of Claim
Rs. 77,000/-
10.
Date of Partial Settlement
-----
11.
Amount of Relief sought
Rs. 77,000/-
12.
Complaint registered
under
Rule No.13.1 (b) of Ins.
Ombudsman
Rules, 2017
Rule 13.1 (b) – any partial or total
repudiation of claims by the Life
insurer, General Insurer or the
Health insurer
13.
Date of hearing/place
18.01.2021
14.
Representation at the
hearing
a) For the complainant
Mr.A.Satyanarayana
b) For the insurer
Mr.Sachin Kumar Verma
15.
Complaint how disposed
DISMISSED
16.
Date of Order/Award
19.01.2021
17) Brief Facts of the Case:
The respondent company had issued an annual Group assurance health plan to M/s Equitas small
finance bank limited wherein the policy issued was individual and in the account of complainant.
During the policy period, the complainant was admitted between 24.03.2020 – 28.03.2020 in 7
STAR Super Specialty Hospital to undergo a surgery for sensory deficit over left L4, S1 dermatones.
His reimbursement claim filed against the insurance policy with respondent was denied. His
request to reconsider his claim had also failed to yield a favorable result and that had led him to
approach this Forum to seek justice.
18) Cause of Complaint: Rejection of reimbursement claim made against
the medical Insurance policy.
a) Complainant’s argument:
In his letter addressed to this Forum, the complainant had stated that
because of an accidental fall, one leg was affected badly and the other leg
too had started to hurt him. He was therefore taken to 7 STAR hospitals
where the doctor upon examining him had stated that the condition was
serious. He had therefore advised him to undergo a surgery within 48
hours failing which he could lose both his legs. When he had showed his
insurance card to the doctor, he was told that this card would not
function in their hospital and was therefore advised to pay the hospital
bills and claim reimbursement from the respondent company. He had
undergone treatment and after settling the bills to hospital, he had
approached the respondent company to reimburse his hospital cost. The
respondent had denied his claim since the patient history submitted by
him did not mention that his was a case related to an accident. The
hospital authorities who had told him that they did not mention the real
cause in the discharge summary because of their haste had issued him a
revised discharge summary sheet. However, when he approached the
respondent with the revised discharge summary sheet, they did not
accept his claim. He had averred that at the age of 63 years when he had
been maintaining good health with no illness prior to the accident and
had been eking his livelihood through daily labor, this incident had
thrown him off gear. He therefore vented that denial of his claim by
respondent amount to cheating the public who had taken insurance
cover from them.
b) Insurer’s argument:
As per the self contained note submitted by the respondent, they have
confirmed that the complainant was covered under the Group Assurance
Health Plan issued to the customers of EQUITAS SMALL FINANCE BANK
for Rs.10,00,000 from 1.1.2020 to 31.1.2021. During the policy period the
complainant was admitted in the hospital and diagnosed with
L3/L4/L5/S1 Prolapse intervertebral disc with canal stenosis and
underwent L4-L5 Laminectomy and L4-L5-S1 Foraminectomy. Since the
Prolapsed Inter Vertibral Disk comes under waiting period of two years
and the claim was lodged within three months of the policy
commencement, it falls outside the scope of the policy and hence
rejected the claim vide their letter dated 3/7/2020. They have not
accepted the accidental fall being the reason for the present
illness/hospitalization since it was not discussed in the Discharge
Summary.
19) Reason for Registration of Complaint:
The insurer rejected the claim preferred by the complainant. As the
complaint falls under Rule 13.1(b) of Insurance Ombudsman Rules, 2017,
it was registered.
20) The following copies of documents were placed for perusal:
a. Policy copy and proposal form
b. Discharge summary
c. Rejection letter
d. Correspondence with insurer
e. SCN
21) Result of the personal hearing with both the parties:
Pursuant to the notices given by this Forum both parties attended the
ONLINE hearing from their respective places on 18.01.2021. During the
course of Hearing the complainant argued that he was hospitalized due
to an accidental fall and he did not have the symptoms prior to the
hospitalization. The comments made in the Medical History of the First
Report was corrected by the Hospital and issued the revised report.
However the Insurance Company has not taken the revised report into
consideration and rejected his claim basing on the comments made in the
First Discharge Summary. He has stated that he was injured due to
sudden fall and the injuries are accidental and not pre-existing. Aggrieved
with the rejection of his claim approached the Forum for justice.
The Respondent insurer has stated that the insured was hospitalized for
the treatment of L3/L4/L5S1 PIVD(Prolapsed Inter Vertibral Disk). The
PIVD falls under the policy exclusion No.5 and a waiting period of 24
months will be applicable for the said disease. Since the complainant has
taken the policy for the first time he has not completed the 24 months
waiting period. Hence they have repudiated the claim since it falls under
the 2 years waiting period. They have further stated that the claim
cannot be admitted as an accident since the hospital records did not
mention the same in their Medical records.
Having heard the arguments of both parties the Forum has framed the
issues to arrive the final conclusion:
(1)Whether the Hospitalization of the complainant is due to an accident
or not? (2)Whether it falls under the policy exclusion of two years waiting
Period?.
As per the First Discharge Summary submitted by the complainant it
was observed that the complainant was admitted on
24.03.2020,diagnosed as “L3/L4/L5/S1 PIVD with canal stenosis”
operated on 25.03.2020 and discharged on 28.03.2020. In the
Medical History it was stated ”Lower back ache since 2 years on
conservative treatment pain not decreased from past 15 days pain
increased and started radiating into the left leg. Patient was having
difficulty in walking and standing”. When his claim was rejected
basing on the medical history he has approached the Hospital and
obtained the revised Discharge Summery rectifying the History as
“Slip and fall at home on 24.03.2020 sustained injury to the lower
back”. It is observed that the hospital authorities have issued the
second Discharge summary without mentioning the reasons for
rectification. They have also not discussed the consequences of the
accidental fall and its effect on the complainant. It was also noted
that under the column of LS SPINE the skin was said to be normal.
No Bruises and wounds were reported in the Medical History. The
revised Discharge Summary failed to correlate the Final Diagnosis
with the accidental fall. It is also noted that the hospital authorities
have not substantiated for the issuance of the revised Discharge
Summary with coherent reasons. Generally, the Medical History
will be obtained from the complainant/his relatives at the time of
joining and the chances of mistakes are very rare. Moreover
Medical History plays a vital role for deciding the Line of Treatment.
Hence we cannot ignore the History of the Patient mentioned in the
first Discharge Summary. The Revised Medical Report submitted,
subsequent to the rejection of the claim, can’t be relied upon or
taken as evidence as the same could have been revised, at the
behest of the complainant. As such the Forum opines that the
complainant has failed to correlate his present illness with the
accidental fall with any documentary proof. Accordingly, the first
issue of accidental fall as the Proximate cause for hospitalization
was not proved satisfactorily and decided against the complainant.
Regarding the second issue of Policy exclusion for two years the
forum has gone through the Waiting Periods of Policy exclusion
No.5. (A) which reads as follows: ”All illnesses, treatments and their
associated complications shall be covered subject to the waiting
periods specified below:
(i) We are not liable for any claim arising due to condition
for which appearance of signs/ symptoms, consultation,
investigation, treatment or admission started within 30
days from policy commencement date, except for the
claims arising due to an accident. However if the
condition is one of the illnesses/ diagnosis or surgical
procedures mentioned in (ii) below, then such coverage
within 30 days would not be available even if arising out
of an accident.
ii. A waiting period of 24 months from the first policy
commencement date will be applicable to the medical and surgical
treatment of illnesses/ diagnosis or surgical procedures mentioned in
Sl.No.(c) Orthopedic-for illness/ diagnosis (irrespective of treatments:
medical or surgical) for Non infective arthritis, Gout and Rheumatism,
Osteoarthritis, Ligament, Tendon and Meniscal tear, prolapsed inter
vertebral disk for which the surgeries/ procedures (irrespective of any
illness/ diagnosis other than cancers) and Joint replacement surgeries.
However this waiting period will not be applicable where the
underlying cause is cancer(s)”.
On perusal of the said Policy exclusions, the treatment for Prolapsed
Inter Vertebral Disk, undergone by the complainant falls under the 24
months Waiting period exclusion.
Since the complainant has taken the policy for the first time and
lodged the claim within the first three months of the policy
commencement, the rejection of the claim by the Respondent Insurer
on the grounds of 24 months waiting period exclusion is justified.
.
Hence the Second issue is decided in favour of the Respondent insurer.
Accordingly the complaint was rejected.
A W A R D
Taking into account the facts & circumstances of the case and the
submissions made by both the parties during the course of the personal
hearing and the information/documents placed on record, the Forum
upheld the rejection of the claim by the Respondent Insurer.
The complaint is Disallowed.
22) The attention of the Insurer is hereby invited to the following provisions of Insurance
Ombudsman Rules, 2017:
m) According to Rule 17(6), the insurer shall comply with the award within 30 days of the receipt of
the award and intimate compliance to the same to the Ombudsman.
n) According to Rule 17(7), the complainant shall be entitled to such interest at a rate per annum
as specified in the regulations, framed under the Insurance Regulatory & Development
Authority of India Act from the date the claim ought to have been settled under the Regulations
till the date of payment of the amount awarded by the Ombudsman.
o) According to Rule 17 (8), the award of Insurance Ombudsman shall be binding on the Insurers.
Dated at Hyderabad on the 19
th
day of January , 2021.
( I. SURESH BABU )
OMBUDSMAN
FOR THE STATES OF A.P.,
TELANGANA AND YANAM CITY
PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, PUNE
(STATE OF MAHARASHTRA EXCEPT MUMBAI METRO)
UNDER SECTION 17 OF THE INSURANCE OMBUDSMAN RULES-2017
OMBUDSMAN–VINAY SAH
CASE OF Mr. Abhay Bucha v/s Star Health & Allied Insurance Co. Ltd
COMPLAINT NO: PUN-G-044-1819-0522
Award No IO/PUN/A/GI/ /2020-21
1.
Name & Address of the
Complainant
Abhay Naginchand Buchha
Amravati
2.
Policy No:
Type of Policy:
P/900000/01/2018/000012
Group Health Policy –M/s Jain International
Organization
3.
Policy period:
31/3/2018-30/3/2019
4.
Sum Insured
Rs.500000/-
5.
Date of inception of first policy:
31/03/2018
6.
Name of the Insured
Mrs. Harsha Buchha – Age: 44 years
7.
Name of the Insurer:
Star Health & Allied Insurance co. Ltd
8.
Reason for repudiation/Partial
Settlement:
Suicide is not covered
9.
Date of receipt of the Complaint:
15/01/2019
10.
Nature of complaint:
Total Repudiation of claim
11.
Amount of Claim:
Rs.1,39,912/-
12.
Insurance Ombudsman Rule
(IOR)2017 under which the
Complaint was registered:
Rule 13 1(b)
13.
Date of hearing/Place:
06/11/2020 (Online)
14.
Representation at the hearing
j. For the Complainant:
Insured himself
k. For the insurer:
Dr. Anjali
15.
Complaint how disposed:
Disallowed
Brief Facts of the Case:
The Complainant filed complaint for rejection of his two claims of hospitalization for his wife. The
complainant with his family (Self, wife, dependent child and dependent parent) covered under
Group policy issued by Respondent Insurer (herein after is called RI) for Jain International
Organization. The sum insured availed by the complainant is on floater basis for Rs. 500000/-.
Both claims were rejected by RI under exclusion no. 8 which is for self-intentional injury.
Contentions of the Complainant:
The complainant’s spouse was admitted from 29/09/2018 to 10/10/2018 at Jan Arpan Hospital,
Lontek with complaints of difficulty in breathing, feeding jejunostomy, urine catheter done, not
responding to commands, tube present, and diagnosed for angioedema related respiratory arrest
with hypoxic brain injury and accordingly reimbursement claim was submitted to the RI. The
claim was rejected under the grounds that the insured patient had history of suicidal tendencies
and treated for corrosive poisoning in June 17.
The insured patient was first admitted to Ganga Care Hospital, Nagpur on 18/07/2018 to
21/07/2018 due to corrosive in food pipe and dilatation process was in progress. On 21/09/2018,
the dilatation was done when the brain injury occurred. The patient was then admitted to Jan
Arpan Hospital in Amravati. As per the declaration submitted by the insured dated 21/11/2018 to
the RI, the insured patient expired on 31/10/2018. The RI has not entertained the case and have
stuck with their earlier decision of repudiation.
Aggrieved with the rejection of the RI, complainant filed complaint with this Forum for resolution.
Contentions of the Respondent:
RI has submitted Self Contained Note (SCN) on 28/2/2019 with all necessary claim papers.
As per SCN, complainant has lodged two claims for his wife
iii. for Hypoxic Brain Injury- period 21/9/2018-10/10/2018
iv. Angioedema related Respiratory Arrest with Hypoxic Brain Injury- period-
10/10/18-31/10/18
The RI has mentioned that as per the Indoor case record of Care Hospital dated 21/9/2018, it is
noted that the insured patient has history of suicidal tendencies and treated for corrosive
poisoning in June 2017, which is intentional self injury.
It is also mentioned by RI that insured patient has undergone for esophageal dilation on
21/9/2018 for corrosive related esophageal stricture. The present admission and treatment of the
insured patient is for the complication of the corrosive poisoning and hence the claim has been
repudiated as per Exclusion No.8 of the policy conditions, which is reproduced hereunder:
Exclusion No.8 – “the company is not liable to make any payment in respect of any expenses for
treatment of a condition arising out of an act of intentional self-injury and use of intoxicating
drugs.”
Result of personal hearing with both the parties (Observations & Conclusions):
During personal hearing held on 06/11/2020 (Online), both the parties reiterated their stand.
After scrutinization of documents and hearing, it is noted that:
8. The insured patient was admitted earlier at Ganga Care Hospital and then at Jan Arpan
Hospital, Amravati;
9. The RI has mentioned that the insured patient had multiple dilatation, bipolar disorder,
not responsive to oral commands, history of corrosive poisoning since 2017, and
suicidal tendencies. The documents also mentions esophageal dilation procedure
undergone by the insured patient on 21/09/2018 for corrosive related esophageal
stricture* *(ingestion of toxicated substance);
10. The forum finds that the insured patient developed cardiorespiratory arrest and the
patient could not be revived and expired on 31/10/2018.
11. As the exclusion clause 8 is operative here beyond doubt, there is no question of
allowing the claim.
In view of the foregoing, forum feels that the claim repudiation has been done in accordance with
the policy conditions issued to the policyholder.
The complaint is disallowed. Award follows:
AWARD
Under the facts and circumstances, the forum finds that the complaint is devoid of
merits and hence stands dismissed.
Dated at Pune on January 13, 2021
VINAY SAH
INSURANCE OMBUDSMAN, PUNE
PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, PUNE
(STATE OF MAHARASHTRA EXCEPT MUMBAI METRO)
UNDER SECTION 16/17 OF THE INSURANCE OMBUDSMAN RULES-2017
OMBUDSMAN–VINAY SAH
CASE OF MR. ABHIJIT PRADHAN V/S THE NEW INDIA ASSURANCE CO.LTD.
COMPLAINT NO: PUN-G-049-1920-0017
Award No IO/PUN/A/GI/ /2020-21
1.
Name & Address of the
Complainant
Mr. Abhijit Avinash Pradhan
The CKP Co-op. Bank Ltd.,
Abhivadan Bldg., 1
st
floor, Opp. Alok Hotel,
Thane – 400604 (M.S.)
2.
Policy No:
Type of Policy:
11250034150400000001
New India Flexi Floater Group Mediclaim
Policy
3.
Policy period:
08/03/2016 to 07/03/2017
4.
Sum Insured/IDV
Rs.2,00,000/- + Buffer Rs.50,000/-
5.
Date of inception of first policy:
Group policy – Continuous renewal
6.
Name & age of the Insured:
Name of the Policyholder:
Mrs. Shashikala Abhijit Pradhan – Age: 43
years
THE CKP COOPERATIVE BANK LTD.
7.
Name of the Insurer:
THE NEW INDIA ASSURANCE CO.LTD.
8.
Reason for repudiation/Partial
Settlement:
Claim amount restricted to balance SI
9.
Date of receipt of the
Complaint:
22/03/2019
10.
Nature of complaint:
Claim settled for lesser amount
11.
Amount of Claim:
Rs.1,09,001/-
12.
Rule of IO Rule under which the
Complaint was registered:
13(1)(b)
13.
Date of hearing/Place:
20/11/2020; (through video-conferencing)
14.
Representation at the hearing
a. For the Complainant:
Himself
b. For the insurer:
Ms.Nivedita Parulekar
15.
Complaint how disposed:
Allowed
Contentions of the Complainant:
Complainant and his family were insured with RI for the period 08/03/2016 to 07/03/2017 under
New India Flexi Floater Group Mediclaim Policy for SI of Rs.2 lakhs. The insured-patient, w/o
complainant Mrs. Shashikala Abhijit Pradhan was admitted in Fortis Hospital Limited from
07/03/2016 to 16/03/2016 for treatment of Carcinoma Breast with Liver Mets with brain with
mild ascites and bills were settled by the insured for an amount of Rs.1,22,801/- out of which the
RI has settled the claim for Rs.13,800/- stating that the payment has been done as per the balance
SI available. The insured is seeking the difference amount of Rs.1,09,001/- from RI.
Despite continuous reminders for the difference amount, RI has not responded nor reverted to
any of the communications given by the insured. In the meantime, the insured patient, Mrs.
Shashikala Pradhan expired on 20/03/2016.
The insured has submitted copies of Final Bill, Discharge Summary, Pharmacy Bills, and Diagnostic
Reports along with complaint letter. As per the insured neither the TPA nor the RI has given
proper response to his queries and aggrieved with the situation, he has approached the forum for
resolution of his grievance.
Contentions of Respondent Insurer (RI):
The RI has vide their communication dated 20/04/2017 to the policyholder have stated that
though the claim amount preferred was Rs.1,22,801/-, the claim was being settled for an amount
of Rs.13,800/- due to amount payable was restricted to balance sum insured of Rs.13,800/- and
hence the excess amount of Rs.1,09,001/- was being deducted.
Result of personal hearing with both the parties (Observations & Conclusions):
During the personal hearing on 20/11/2020 (Online), both the parties reiterated their respective
stand.
From the available documents it is noted that:
o RI had issued New India Flexi Floater Group Mediclaim Policy for the period
08/03/2016 to 07/03/2017 issued to The CKP Co-op. Bank Ltd. with a family floater SI
of Rs.2 lakhs + Buffer of Rs.50,000/- to the insured through the policyholder;
o The insured patient was suffering from abdominal pain and was admitted on
07/03/2016 to Fortis Hospital Limited and was diagnosed and treated for Carcinoma
of Breast and was discharged on 16/06/2016;
By mail dt.19/11/2020, RI has conveyed following information:
‘We have contacted the Insured Mr Abhijit Pradhan inconnection to the said grievance. The data
provided was not correct but based on the information received from him regarding claims settled
by Raksha TPA we traced the policy no on which the claim was registered: -
11250034140400000001 There are 2 claims paid ₹85547 + ₹34975. Under the said policy.
Also we would like to inform you that the Proposer is CKP Co-operative Bank and 1st GMC policy
was for the period 28-1-2014 to 27-1.2015 (11250034130200000001) and a fresh policy was taken
by Bank for the period 19.3.2015 to 18.3.2016 (11250034140400000001).
Hence due to unavailability of correct policy no on which claim was lodged we are unable to
provide any additional information or written statement for this case. In case the same is provided
by the Claimant we may be in a position solve the grievance.’
During the hearing, the RI was made aware with the policies and the buffer amount available for
the members in the group. After this, the RI has now confirmed over mail as quoted below:
‘The Insured Mr Abhijeet Pradhan had visited our office in Jan 2021 and we had asked him to hand
over all related bills and claim papers along with receipt. The same has been submitted by him via
registered courier 10.2.2021. We have sent the same to Raksha TPA for review and have called for
all claims lodged by Mr A Pradhan under the policy for spouse Mrs Shashikala Pradhan. The policy
sum insured is Rs 200000/- + 50000 buffer.
At the time of the hearing we did not have any details of policy under which this claim falls hence
we were unable to send the SCN. The same was also informed to the Hon Ombudsman during the
Hearing held on 9.11.2020. The Ombudsman office sent us the policy no and copy.’
In view of this, complaint is admitted.
Award follows:
AWARD
Under the facts and circumstances of the case, the Respondent Insurer is directed to pay the
balance expenses incurred towards the treatment of the insured patient, maximum up to the
sum insured inclusive of buffer amount, available to the insured patient in that relevant policy
year.
The award is to be settled within one month from the date of receipt of this award failing which
it will attract interest at the prevailing bank rate plus 2% extra from the date of rejection of the
claim till the date of payment of this award.
The attention of the Complainant and the Insurer is hereby invited to the following provisions of
Insurance Ombudsman Rules 2017:
17(6) the insurer shall comply with the award within thirty days of the receipt of the award and
intimate compliance of the same to the Ombudsman.
17(8) the award of Insurance Ombudsman shall be binding on the insurers.
Dated: at Pune this 19
th
day of February 2021
VINAY SAH
Insurance Ombudsman, Pune
PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, PUNE
(STATE OF MAHARASHTRA EXCEPT MUMBAI METRO)
UNDER SECTION 16/17 OF THE INSURANCE OMBUDSMAN RULES-2017
OMBUDSMAN–VINAY SAH
CASE OF Mr. Anant Telang Vs. The National Insurance Company Ltd.
COMPLAINT NO: PUN-G-048-1819-0687
Award No IO/PUN/A/GI/ /2020-2021
1.
Name & Address of the
Complainant
Mr. Anant Telang
Flat No. D 403, Ganga Cypress CHS,
Near Ashwini International School, Tathawade,
Pune – 411033 (M.S.)
2.
Policy No:
Type of Policy:
271005/4/16/8500000851
BOI National Swasthya BIMA policy
3.
Policy period:
19/09/2016 to 18/09/2017
4.
Sum Insured/IDV
Rs.5 lakhs
5.
Date of inception of first policy:
19/09/2016
6.
Name & age of the Insured:
Name of the Policyholder:
Mrs. Alka Telang, Age – 64 years
Mr. Anant Telang
7.
Name of the Insurer:
The National Insurance Company Ltd.
8.
Reason for rejection /Partial
Settlement:
Treatment taken on OPD basis.
9.
Date of receipt of the Complaint:
18/03/2019
10.
Nature of complaint:
Rejection of cancer treatment
11.
Amount of Claim:
Rs.1,83,099/-
12.
Rule of IOR 2017 under which the
Complaint was registered:
13(1)(b)
13.
Date of hearing/Place:
6/11/2020; (through video-conferencing)
14.
Representation at the hearing
c. For the Complainant:
Himself
d. For the insurer:
Ms.Sunita Badadal; TPA Dr.Navin
15.
Complaint how disposed:
Disllowed
Contentions of the Complainant:
Complainant and his family were insured with the Respondent Insurer (RI) under the above policy
for the period 19/09/2016 to 18/09/2017. The insured patient aged 64 years was admitted to
Somaiya Ayurvihar, Mumbai for treatment of carcinoma breast and was being given injections.
The insured has paid an amount of Rs.1,83,099/- to the hospital towards the treatment to the
treating hospital.
The complainant has stated that the insured patient was suffering from Carcinoma Breast,
metastatic to the bones and was having pain in the left side of neck and left upper arm since 15
days. She was under treatment since the last 3 years and the claim papers were sent to the RI on
17/07/2017. The RI advised him to accept Rs.65,100/- out of Rs.1,83,100/- in full and final
settlement which the insured has not agreed. The doctor has advised them to go for Injection
Fulvestrant for bone strength for multiple bony mets. The treatment given by the hospital to the
inured patient was Chemotherapy.
The claims have not been settled by the RI till date and aggrieved with this situation; the
complainant has approached the forum for the resolution of his grievance.
Contentions of the Respondent Insurer (RI):
The Self contained note received from the RI shows following details:
Year
Policy No.
Start date
End date
Claim details
2014-15
2710054814850000350
11-07-2014
10-07-2015
No claim is reported
2015-16
2710054815850000819
18-09-2015
17-09-2015
No claim is reported.
2016-17
2710054816850000851
19-09-2016
18-09-2017
Said claim reported and rejected
2017-18
271005501710000950
19-09-2017
18-09-2018
15 claims of Rs. 5,00,000/- paid.
2018-19
271005501810000992
19-09-2018
18-09-2019
1 claim Rs. 1,17,709/-
c) 2014-15: This is the first BOI Swasthya Bima Policy the complainant had obtained from
RI. Proposal form filled in by the complainant is submitted by the RI.
d) 2015-16: Against renewal, RI received the premium from the bankers on 18/09/2015
vide their pay in slip no. 019261 dt.10/09/2015. Because of the gap of 70 days, the RI
issued the policy as a fresh one and not as a renewal, but no fresh proposal was
obtained as the details were same as per the expiring policy.
e) 2016-17: Policy was renewed as first renewal.
Claim details of the repudiated claim:
First claim in respect of the above policy was submitted to their Medcorp TPA on 12/07/17 for
claim of Rs.1,83,099/- for Mrs. Alka Telang
The claim was rejected for the following reasons:
d. On non-disclosure of material fact: This fact is established form the following documents:
(iii) Dr.Anupama Borkars’s certificate dt. 31/8/17 shows insured-Mrs.Alka Telang’s history
of breast cancer from Sept.2015.
(iv) As per Thyrocare Nuclear report dt.27/6/17, it was a case of carcinoma right breast.
PET-CT scan was done in Sept.2015 and Aug. 2016. This material fact was not disclosed
by the insured.
e. On pre-existing condition of the disease. As the policy of 2015-16 was issued as a fresh
policy, the present claim was treated as pre-existing disease as per policy clause no. 4.1
reproduced below:
Pre-existing disease (PED): All pre-existing disease. Such diseases shall be covered after
the policy has been continuously in force for 36 months. Any complication arising
from pre-existing ailment/disease/injuries will be considered as a part of the pre-
existing health condition or disease.
f. There was no 24 hours admission in the hospital. Hence under policy clause 3.13 also, the
claim was rejected.
The claim is rejected as per Clause No.3.13, which is reproduced as under:
a. –Hospitalization means admission in a hospital as an in-patient for a
minimum period of 24 (twenty four) consecutive hours. Hence, hospitalization
less than 24 hrs. is not payable.
g. Also they have wrongly paid 15 various claims of total amount of Rs.5 lacs on policy period
2017-18 which were not payable under PED clause.
h. For all these claims paid wrongly by their TPA, they have initiated the recovery from their
then TPA Vipul Medcorp Insurance TPA.
Result of personal hearing with both the parties (Observations & Conclusions):
During the personal hearing on 6/11/2020 (through video-conferencing) both the parties
reiterated their respective stand.
From the documents, it is observed that,
● There was delay of 70 days in renewal of the policy of the year
● In view of the vague reference of the detection of CA in Sept. 2015 and the issue of second
year policy as a fresh one, in view of the gap of 70 days, which was not condoned by the
RI, the forum asked the RI to submit the specific claim document which would establish
the PED nature of the CA. Accordingly, the RI have submitted the discharge summary of
Asian Ayurvihar, wherein at page no. 18 there is mention of date of PET CT Scan as 9/9/15.
Policy period is from 18/09/15 to 17/09/15. This amply clears the fact that the treatment
falls under PED in view of the delay of 70 days not condoned by the RI, as per their
contention.
In view of the above facts, this forum is not inclined to award in favour of the complainant.
AWARD
Under the facts and circumstances, complaint is dismissed.
Dated: at Pune this 20
th
day of January 2021
VINAY SAH
Insurance Ombudsman, Pune
PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, PUNE
(STATE OF MAHARASHTRA EXCEPT MUMBAI METRO)
UNDER SECTION 17 OF THE INSURANCE OMBUDSMAN RULES-2017
OMBUDSMAN– VINAY SAH
CASE OF Mr Bhaskar Shandilya V/S ICIC Lombard General Insurance Co.Ltd.
COMPLAINT NO: PUN-H-020-2021-0217
Award No IO/PUN/A/H/ /2020-21
1.
Name & Address of the
Complainant
Mr Bhaskar Shandilya
Panvel
2.
Policy No:
Type of Policy:
4016/X/154793890/01/000
Group Health Floater Ins- Apollo Logisolutions Ltd.
3.
Policy period:
01/09/2019 To 31/08//2020
4.
Sum Insured
Rs. 500000
5.
Date of inception of first policy:
6.
Name of the Insured:
Name of the Policyholder:
Mr LallanMishra Age 60
Mr Lallan Mishra
7.
Name of the Insurer:
ICICI Lombard Gen Ins. Ltd.
8.
Reason for repudiation/Partial
Settlement:
Partial settlement of Claim
9.
Date of receipt of the Complaint:
02/11/2020
10.
Nature of complaint:
Partial settlement of of claim
11.
Amount of Claim:
Rs. 201251
12.
Insurance Ombudsman Rule
(IOR)2017 under which the
Complaint was registered:
Rule 13 1 (b)
13.
Date of hearing/Place:
10/11/2020 Online
14.
Representation at the hearing
e. For the Complainant
Himself
f. For the Insurer
Mr.Karan Bagdai; Dr.Pankaj Srivastava
15
Complaint how disposed
Allowed
16
Date of Award:
25-11-2020
Contentions of the Complainant:-
The Complainant’s father Lallan Mishra, was covered under Group Mediclaim policy of RI. Due to
high grade fever and dry coughing for 3-4 days, he was admitted at Panacea Hospital, New Panvel.
On 24/08/2020. He was diagnosed to have corona, acute respiratory failure and pneumonia. He
was in very critical health condition; hence kept on ventilator. The total hospitalization expenses
incurred are 4.31 lakhs whereas ICICI Lombard have sanctioned Rs 3,63,882/- out of which they
have paid him Rs 1,98,749/- and balance of Rs 1,65,133 was to be reimbursed. He raised questions
on deduction of Rs 24000/- on account of ABG report.
Contentions of the Respondent Insurer(RI):-
Details
Claimed
Amount
Sanctioned
Amount
Disallowed
Amount
Disallowed Reasons
Final Bill
Rs 136450/-
Rs 128550/-
Rs 7900/-
Deducted as BMW, Reg charges not payable.
Bills Falling
Under
Hospitalization
Period
Rs 292179/-
Rs 235332/-
Rs 59444/-
Rs.2500/- deducted as ppe kit limit exhausted;
Rs.13768/-
Facemask,cap,diaper,sanitizer,patient kit,mask
charges not payable; Rs.7500/-deducted as ppe
kit limit exhausted; Rs.24000/-deducted as ABG
reports not furnished; Rs. 11676/- deducted
from medicines & investigations (CBC & CRP)
inclusive of State Govt. package.
Pre-post Bills
Rs 2597/-
Total Claimed
Amount
Rs 431226/-
Rs 363882/-
Rs 67344/-
Further, the Company vide mail dated November 10, 2020 has informed the complainant that the
balance claim amount of Rs.165,133/- is under process and have shared the deduction details for
the non-payable amount of Rs.67344/-. If the complainant submits the ABG reports to the
Company then an amount of Rs.24000/- can be assessed and processed subject to the limits of
the guidelines.
Result of personal hearing with both the parties (Observations & Conclusions):
During the personal hearing on 10/11/2020 (through video-conferencing) both the parties
reiterated their stand.
It is observed that there is dispute regarding non payment of Rs.24000/- towards ABG reports.
The RI representative reiterated that they are ready to pay this amount on submission of the
reports. The complainant agreed to submit the same. RI have confirmed the receipt of the same
subsequently.
In view of this, the claim thus will get settled for Rs.3,63,882/-
Plus ABG reports exp. Rs.24,000/-
Total amount of claim approval Rs.3,87,882/-
AWARD
Under the facts and circumstances of the case, the Respondent is directed to pay balance
amount from the approved claim of Rs. 3,87,882/- to the complainant towards full and final
settlement of his complaint.
The attention of the Complainant and the Insurer is hereby invited to the following provisions of
Insurance Ombudsman Rules 2017:
17(6) the insurer shall comply with the award within thirty days of the receipt of the award and
intimate compliance of the same to the Ombudsman.
17(8) the award of Insurance Ombudsman shall be binding on the insurers.
Dated: On 25
th
November 2020 at Pune
VINAY SAH
Insurance Ombudsman
Pune
PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, PUNE
(STATE OF MAHARASHTRA EXCEPT MUMBAI METRO)
UNDER SECTION 17 OF THE INSURANCE OMBUDSMAN RULES-2017
OMBUDSMAN–VINAY SAH
CASE OF Mr. Debashish Mitra V/s United India Insurance Co. Ltd
COMPLAINT NO: PUN-G-051-1819-0577
Award No IO/PUN/A/GI/ /2020-21
1.
Name & Address of the
Complainant
Mr. Debashish Mitra
Kalyan
2.
Policy No:
0515002817P110901973
Type of Policy:
Group Policy for Employee of HDFC Ergo
3.
Policy period:
20/10/2017-2018
4.
Sum Insured
Rs.600000/-
5.
Date of inception of first policy:
Tailor-made policy
6.
Name of the Policyholder:
Mr. Debashish Mitra
7.
Name of the Insurer:
United India Insurance Co. Ltd
8.
Reason for repudiation/Partial
Settlement:
Treatment for Crohn’s disease with Fistula not
required hospitalization
9.
Date of receipt of the Complaint:
04/02/2019
10.
Nature of complaint:
Total Repudiation of Claim
11.
Amount of Claim:
Rs. 80000/-
12.
Insurance Ombudsman Rule
(IOR)2017 under which the
Complaint was registered:
Rule 13 1(b)
13.
Date of hearing/Place:
06/11/2020 (Online)
14.
Representation at the hearing
g. For the Complainant:
Ms. Nisha Sharma (W/O Complainant)
h. For the insurer:
Mr. Abhay Murgad
15.
Complaint how disposed:
Allowed
Contentions of the Complainant:
The Complainant is the employee of HDFC ERGO Gen. Insurance Co. Ltd. who have purchased
Group Mediclaim policy with Respondent Insurer (herein after is called RI) for their Employees for
the above period.
Apollo has settled the claim partially.
The complainant had claimed under this policy towards treatment taken for Crohn’s disease. The
treatment taken by the complainant for the disease was monoclonal antibody treatment of Inj.
Infliximab on day care basis. The treatment was costly. Doctor has advised 10 doses minimum.
The complainant has undergone through this therapy and claimed for reimbursement. The
complainant has explained through his mail for requirement of treatment on day care basis.
Employer who is also in Insurance business took the second opinion of Dr. Renuka. As per
explanatory mail of Dr. Renuka Kanvinde, Inj. Infliximab is a biotherapy treatment for active
Crohn’s disease this is administered as an IV infusion slowly over a period of 2-3 hrs. The
administration needs to be done in a sterile environment in a hospital as there are fair chances of
adverse reaction. So, this kind of treatment requires hospitalization - not necessarily for over 24
hrs and hence should be considered under day care. However, RI has not agreed with the
explanation given and rejected the claim.
Contentions of the Respondent:
RI has submitted Self Contained Note on 11/3/2019.
As per SCN, Mr. Debashish Mitra, aged 36 years was hospitalized at Upasani Super Specialty
Hospital on 9/12/17 to 10/12/2017 and 25/12/2017 to 26/12/2017 for the procedure of Crohn’s
disease, Active terminal lleus, underwent Inj. Infliximab administration.
Hospitalization for this procedure is not covered in the policy. Hence not considered the claim for
admissibility based on condition no. 1.1 of the policy.
‘1.1 NOW THIS POLICY WITNESSES that subject to the terms, conditions, exclusions and definitions
contained herein or endorsed, or otherwise expressed here on the Company undertakes that
during the period stated in the Schedule, if any insured person(s) contracts any disease or suffers
from any illness (hereinafter called DISEASE) or sustains any bodily injury through accident
(hereinafter called INJURY) and if such disease or injury requires such insured Person, upon the
advice of a duly qualified Physician/Medical Specialist/Medical practitioner (hereinafter called
MEDICAL PRACTITIONER) or of a duly qualified Surgeon (hereinafter called SURGEON) to incur
hospitalisation/domiciliary hospitalisation expenses for medical/surgical treatment at any Nursing
Home/Hospital in India as herein defined (hereinafter called HOSPITAL) as an inpatient, the
Company will pay through TPA to the Hospital / Nursing Home or the Insured Person the amount
of such expenses incurred as are medically necessary and reasonable and customary in respect
thereof by or on behalf of such Insured Person but not exceeding the Sum Insured in aggregate in
any one period of insurance stated in the schedule hereto.’
Result of personal hearing with both the parties (Observations & Conclusions):
During Personal hearing held on 06/11/2020 (Online), and both the parties reiterated their stand.
In view of the day care treatment taken by the complainant, forum asked the RI to see the
possibility of considering this claim payment. In response, it was defended by the RI that the said
treatment is not listed in the day care treatment provided in the said policy. Hence, the forum
asked the RI to share the MOU/ policy clauses of this group policy.
It is observed from the group policy that though the specific disease is not mentioned in the list,
but it is to be noted that this list is not an exhaustive list, but given as ‘for example’ basis as
revealed from the wordings quoted in the policy as:
‘Expenses on hospitalization for minimum period of 24 hours are admissible. However, this time
limit is not applied to specific treatments, such as:’
The word ‘such as’ implies the meaning ‘for example’ and hence it is not an exhaustive list. The
treatment through inj. Infliximab is a day care treatment as observed as well as certified by the
doctor of group policy holder M/s HDFC ERGO. In view of this, claim is admissible under day care
treatment provided under the policy.
Award follows:
AWARD
Under the facts and circumstances, the RI is directed to pay Rs.80,000/-less compulsory
deductibles if any towards full and final settlement of the complaint adhering to the following
rules of IOR 2017.
The award is to be complied with within one month from the date of receipt of this award
failing which it will attract interest at the applicable bank rate plus 2% extra from the date of
rejection of the claim till the date of payment of this award.
The attention of the Complainant and the Insurer is hereby invited to the following provisions of
Insurance Ombudsman Rules 2017:
17(6) the insurer shall comply with the award within thirty days of the receipt of the award and
intimate compliance of the same to the Ombudsman.
17(8) the award of Insurance Ombudsman shall be binding on the insurers.
Dated: at Pune this 14
th
day of January 2021
VINAY SAH
Insurance Ombudsman, Pune
PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, PUNE
(STATE OF MAHARASHTRA EXCEPT MUMBAI METRO)
UNDER SECTION 16/17 OF THE INSURANCE OMBUDSMAN RULES-2017
OMBUDSMAN–VINAY SAH
CASE OF Mr. Devendra Bapna Vs. Star Health & Allied Insurance Co. Ltd.
COMPLAINT NO: PUN-G-044-1819-0673
Award No IO/PUN/A/GI/ /2020-2021
1.
Name & Address of the
Complainant
Mr. Devendra Bapna
Radha Hari Niwas CHS, Opp. Ratan Talkies,
B-Wing 302, Lokmanya Tilak Marg, Panvel – 410206
2.
Policy No:
Type of Policy:
P/900000/01/2018/000012
Group Mediclaim Insurance Policy (JIO)
3.
Policy period:
31/03/2018 to 30/03/2019
4.
Sum Insured/IDV
Rs.5 lakhs
5.
Date of inception of first
policy:
Not known – Group policy
6.
Name & age of the Insured:
Name of the Policyholder:
Mrs. Manohari Devi Bapna – Age: 66 years
M/s Jain International Organization
7.
Name of the Insurer:
Star Health & Allied Insurance Co. Ltd.
8.
Reason for rejection /Partial
Settlement:
Claims are settled as per policy terms – 25% co-pay
deducted due to PED.
9.
Date of receipt of the
Complaint:
11/03/2019
10.
Nature of complaint:
Hospitalization claim settled for lesser amount
11.
Amount of Claim:
Rs.70,735/-
12.
Rule of IOR 2017 under which
the Complaint was registered:
13(1)(b)
13.
Date of hearing/Place:
06/11/2020 (Online)
14.
Representation at the hearing
i. For the Complainant:
Insured himself
j. For the insurer:
Dr. Anjali
15.
Complaint how disposed:
Allowed
Brief Facts of the Case:
Complainant and his family were insured with the Respondent Insurer (RI) under the above policy
for the period 31/03/2018 to 30/03/2019 for a SI of Rs.5 lakhs. The insured patient Smt. Manohari
Devi Bapna mother of the complainant aged 67 years was admitted to Gune Hospital, Pune twice
and one admission was done at Global Hospital for treatment of intestinal obstruction procedure.
The claim was settled by the RI by deducting 25% co-pay in all the three claims on the grounds
that the ailment was a pre-existing one.
Contentions of the Complainant:
After the claim documents of the insured patient, were submitted to the RI for reimbursement,
the RI after going through the records, settled the claim after deducting 25% co-pay from all the
three claims as the RI felt that the disease was PED. The insured has settled the hospitalization bill
at all the three hospitals amounting to Rs.3,35,335/- as against an amount of Rs.2,11,340/-
reimbursed to him. The insured is not agreeable for deduction of co-pay as he has stated that the
disease was not a pre-existing one.
The total claims settled and deducted against the three admissions are as under:
Name of
Hospital
Period of stay
at hospital
Bill paid at
hospital
(Rs.)
Claim
settled
(Rs.)
Deduction
(Rs.)
Reason
Gune Hospital
03/11/2018 to
10/11/018
53,670/-
38,881/-
12,960/-
25% co-pay
Global
Hospital
11/11/2018 to
20/11/2018
2,16,129/-
127,248/-
42,416/-
25% co-pay
Gune Hospital
20/11/2018 to
03/12/208
65,536/-
45,211/-
15,359/-
25% co-pay
The complainant has stated that the insured patient was diagnosed with sub-acute intestinal
obstruction and was admitted to Gune Hospital and accordingly claim was settled as per policy
conditions and deducting co-pay. Subsequently, the same insured patient was again admitted to
the same Hospital and was diagnosed with infected umbilical port + abscess and discharging
sinus. The RI has once again settled the claim as per the earlier norms. Thereafter, the insured
patient was again admitted at Global Hospital on 11/11/2018 and she was diagnosed for intestinal
obstruction and when the cashless facility was requested by the insured it was rejected vide their
letter dated 13/11/2018. After discharge of the patient on 20/11/2018, reimbursement claim was
submitted by the insured for Rs.2,16,129/- and the claim was settled for an amount of
Rs.1,27,248/- after deducting non-payables and 25% co-pay.
The difference in claims have not been settled by the RI till date and aggrieved with this situation;
the complainant has approached the forum for the resolution of his grievance.
Contentions of the Respondent Insurer (RI):
RI contends that the insured patient a k/c/o DM and HT, was admitted for recurrent episodes of
Intestinal obstruction- managed both conservatively and surgically. During the course of
hospitalization, patient was diagnosed with right renal mass and radical Nephroctomy done for
the same. Patient was readmitted for post operative wound infection and secondary suturing. as
per CT report taken during 14/12/2017 – 19/12/2017, it is clear that the intestinal obstruction is
due to adhesive bands which are formed due to previous abdominal surgery, namely
Hysterectomy.
From the above findings, it is noted that the intestinal obstruction being a complication of the
adhesion formed due to previous surgery. Hence it is PED.
Therefore, all three claims are processed as per T&C of the policy deducting 25% as co pay.
Result of personal hearing with both the parties (Observations & Conclusions):
During the personal hearing on 06/11/2020 (Online) both the parties reiterated their respective
stand.
From the available documents, forum notes that:
a) The insured patient was admitted at
the hospital for availing treatment of
sub-acute intestinal obstruction and
infection of umbilical port and RI has
settled all the three claims after
deducting the non-payables and 25%
co-pay as the disease of the insured
patient was considered as PED;
b) The Group Mediclaim policy has its
own sub-limits and co-payment share
as per the SI opted by them. The
normal co-pay is 10% but in case of
PED, the co-pay is deducted @ 25%.
c) The insured, not accepting deduction
as above, was in touch with the RI for
review and reconsidering his claim but
they have informed him that the
claims settled was the maximum
payable under the terms and
conditions of the policy issued to the
policyholder;
d) As per the contention of RI, the
present condition is a complication of
previous surgery of Hysterectomy.
Which was performed 15 years back.
Linking the present condition to a
surgery that was done as long back as
15 years is stretching the concept of
PED too far.
e) Complainant has obtained certificates
from both, Gune hosp. and Global
Hosp. Both doctors have declared that
the patient was admitted and treated
for ‘Acute intestinal obstruction’ and
‘infected umbilical port with abscess &
discharging sinus’. This condition is not
related to anything prior but of recent
origin.
The forum feels that it is not correct to apply co pay on account of PED in this case and hence the
co-pay should be deducted @10% and not 25% as done by the RI. The complaint is allowed.
Awards follows:
AWARD
Taking into account the facts and circumstances of the case, the Respondent Insurer is
directed to recalculate the claims by deducting only 10% co-pay and pay the difference
amount to the complainant after disallowing non-medical items as per the terms and
conditions of the policy towards full and final settlement of this complaint adhering to
the following rules of IOR.
The attention of the Complainant and the Insurer is hereby invited to the following provisions of
Insurance Ombudsman Rules 2017:
17(6) the insurer shall comply with the award within thirty days of the receipt of the award and
intimate compliance of the same to the Ombudsman.
17(8) the award of Insurance Ombudsman shall be binding on the insurers.
Dated at Pune this 13
th
day of January, 2021
VINAY SAH
Insurance Ombudsman, Pune
PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, PUNE
(STATE OF MAHARASHTRA EXCEPT MUMBAI METRO)
UNDER SECTION 16/17 OF THE INSURANCE OMBUDSMAN RULES-2017
OMBUDSMAN – VINAY SAH
CASE OF Mr. Kamlesh Mutha Vs. Star Health & Allied Insurance Co. Ltd.
COMPLAINT NO: PUN-G-044-1819-0597
Award No IO/PUN/A/GI/ /2020-2021
1.
Name & Address of the
Complainant
Mr. Kamlesh Mutha
Navjeevan Hospital, Paithangate,
B/H Old Hotel Ripss, Aurangabad - 431002
2.
Policy No:
Type of Policy:
P/900000/01/2018/000012
Group Health Insurance (JIO)
3.
Policy period:
31/03/2018 to 30/03/2019
4.
Sum Insured/IDV
Rs.5 lakhs
5.
Date of inception of first policy:
Group Policy – Continuous renewal
6.
Name & age of the Insured:
Name of the Policyholder:
Mrs. Nirmala Satish Mutha – Age: 60 years
M/s Jain International Organization (JIO)
7.
Name of the Insurer:
Star Health & Allied Insurance Co. Ltd.
8.
Reason for rejection /Partial
Settlement:
Maximum payable amount has already been
settled
9.
Date of receipt of the Complaint:
04/02/2019
10.
Nature of complaint:
Claim settled for lesser amount
11.
Amount of Claim:
Rs.1,03,487/-
12.
Rule of IOR 2017 under which the
Complaint was registered:
13(1)(b)
13.
Date of hearing/Place:
10/11/2020 (Online)
14.
Representation at the hearing
k. For the Complainant:
Himself
l. For the insurer:
Dr. Anjali Rathod
15.
Complaint how disposed:
Allowed
Brief Facts of the Case:
Complainant and his family were insured with the Respondent Insurer (RI) under the above policy
for the period 31/03/2018 to 30/03/2019. The insured patient, Mrs. Nirmala Satish Mutha, aged
60 years was admitted to Kamalnayan Bajaj Hospital, Aurangabad and Seth Nandalal Dhoot
Hospital, Aurangabad for treatment of Adenocarcinoma of Endometrium. The claim was partially
rejected by the RI on the grounds that the claim was settled as per the maximum eligibility as per
the terms and conditions of the policy.
Contentions of the Complainant:
After the claim documents of the insured patient, were submitted to the RI for reimbursement,
the RI after going through the records, settled the claim partially for Rs.1,34,000/- out of total
hospitalization bill of Rs.3,23,695/- and the complainant is seeking the difference in amount of
Rs.1,89,695/-. The details of the transactions towards the treatment of Cancer of Endometrium
are given hereunder:
Name of Hospital
Admission
details
Amount paid at
Hospital (Rs.)
Amount
settled by RI
(Rs.)
Deduction
(Rs.)
Kamalnayan Bajaj
Hospital, Aurangabad
03/10/2018
to
08/10/2018
1,17,859/-
50,000/-
67,859/-
Seth Nandlal Dhoot
Hospital, Auranagabad
17/11/2018
to
28/12/2018
2,05,836/-
84,000/-
1,21,836/-
The complainant has stated that the insured patient, Mrs. Nirmala Satish Mutha (M/o
complainant) was suffering from post-menopausal problems and bleeding and was diagnosed for
cancer of endometrium. The patient admitted on 03/10/2018 to Kamalnayan Bajaj Hospital, after
undergoing hysterectomy procedure, was discharged on 08/10/2018. She was again admitted to
Seth Nandalal Dhoot Hospital on 17/11/2018. Diagnosis being ‘cancer of endometrium post
operation’. She was discharged on 28/12/2018 after treatment.
The insured has represented his partial rejection of claim to the Grievance Cell of the RI for the
difference in amount but as there was no response from the RI, the complainant has approached
the forum for the resolution of his grievance.
Contentions of the Respondent Insurer (RI):
The RI has stated that the patient was taken to the hospital on multiple times for treatment of
cancer of endometrium and another hospitalization for undergoing the procedure of Cancer of
Endometrium post operation, both in Aurangabad city.
The insured has preferred two claims in the second year of the policy wherein the insured patient,
Mrs. Nirmala Satish Mutha was admitted in Kamalnayan Bajaj Hospital, Aurangabad on
03/10/2018 and was diagnosed as cancer of endometrium and the procedure done was
Laparascopic Bilateral Saplingo and after the procedure was discharged on 08/10/2018. The claim
was processed and after considering the sub-limit of Hysterectomy, an amount of Rs.50,000/- was
paid to the hospital.
Subsequently, the insured patient was again admitted to Seth Nandlal Dhoot Hospital,
Aurangabad on 17/11/2018 and she was diagnosed for cancer of endometrium post operation
and after treatment was discharged on 28/12/2018. Initially, an amount of Rs.50,000/- was
approved and was enhanced to Rs.84,000/- and the same was settled on 21/01/2019 towards
treatment of cancer / radiotherapy.
Before hearing, RI again re-evaluated the claim and offered Rs.86000/- contending that this will
exhaust the limit of Rs. 2,20,000/- provided for cancer treatment.
RI contends that, the maximum amount payable in respect of HYSTERECTOMY for the sum insured
of Rs. 5 lakh is Rs. 50,000/-. and in respect of second hospitalization, the RADIATION RAPIDARK
PER FRACTION (Radiotherapy charges) Rs. 86,000/- is the only payable expenses in treatment of
cancer. Thus, the maximum amount payable towards the claims was already paid.
Result of personal hearing with both the parties (Observations & Conclusions):
During the personal online hearing through video conferencing, on 10/11/2020 (Online), both the
parties reiterated their respective stand.
It is observed that, the said policy has capping of Rs. 50,000/- for Hysterectomy and of Rs.
2,20,000/- for Cancer treatment for the covered persons having SI of 5 lakh. During the hearing, RI
offered to pay additional 86,000/- stating that, that is the maximum amount they can pay
considering the sub limit for cancer. However, the complainant demanded full expenses of 2
nd
hospitalization to be reimbursed.
Forum finds that there are 2 hospitalisations. In case of 1
st
hospitalization, hysterectomy was
performed, for which Rs. 50,000/- was reimbursed as per sub limit, out of claimed amount of
Rs.1,17,859/-. This aspect is not in dispute from the complainant’s side. His contention is for
payment of full claim of Rs. 1,87,487/- (after hospital discount) for the second hospitalization as it
is well within the sublimit of 2,20,000/- provided for cancer (CA)treatment. While offering
additional 86,000/-, RI is taking into account Rs.50,000/- paid for 1
st
hospitalization, contending
that the total amount payable is as under, considering the full treatment as a cancer treatment:
Rs.50,000/- paid for hysterectomy, in 1
st
hospitalisation;
Rs.84,000/- paid under 2
nd
hospitalization
Rs.86,000/- they have offered now towards balance amount for CA treatment
Forum differs with the contention of the RI and finds that both the claims should be considered
separately for applying sub limits as the limit for CA is irrespective of the type/part of CA an
insured is suffering from. If the same person would have suffered with CA of the different part
other than uterus, the RI would have considered this limit as separate from hysterectomy. As
coincidently, the insured patient has suffered CA of uterus, RI has clubbed the limit for CA for both
the treatments.
In view of this, forum is of the view that the expense of Rs. 1,87,487/- are to be paid in full as it is
well within the sublimit of Rs.2.20.000/- provided for CA treatment. As Rs. 84000/- is already paid,
now balance remains to be paid is 1,03,487/-.
The complaint is allowed. Award follows:
AWARD
Under the facts and circumstances of the case, the Respondent is directed to pay Rs.1,03,487/-
less deductibles if any, to the complainant towards full and final settlement of this complaint.
The award is to be satisfied within one month from the date of receipt of this award failing
which it will attract interest at the applicable bank rate plus 2% extra from the date of rejection
of the claim till the date of payment of this award.
The attention of the Complainant and the Insurer is hereby invited to the following provisions of
Insurance Ombudsman Rules 2017:
17(6) the insurer shall comply with the award within thirty days of the receipt of the award and
intimate compliance of the same to the Ombudsman.
17(8) the award of Insurance Ombudsman shall be binding on the insurers.
Dated 13
TH
February, 2021 at Pune
VINAY SAH
Insurance Ombudsman, Pune
PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, PUNE
(STATE OF MAHARASHTRA EXCEPT MUMBAI METRO)
UNDER SECTION 17 OF THE INSURANCE OMBUDSMAN RULES-2017
OMBUDSMAN– VINAY SAH
CASE OF Mr Kishor Mahajan V/S ICICI Lombard General Insurance Co.Ltd.
COMPLAINT NO: PUN-H-020-2021-0222
Award No IO/PUN/A/H/ /2020-21
1.
Name & Address of the
Complainant
Mr Kishor Mahajan
Waghadi Dist Jalgaon
2.
Policy No:
Type of Policy:
4016/130173645/03/000
Group Mediclaim- 3 I- Infotech Ltd.
3.
Policy period:
01/04/2020 To 31/03//2021
4.
Sum Insured
5.
Date of inception of first policy:
01/04/2020
6.
Name of the Insured:
Name of the Policyholder:
Mr Kishor Mahajan
Mr Kishor Mahajan
7.
Name of the Insurer:
ICICI Lombard Gen Ins. Ltd.
8.
Reason for repudiation/Partial
Settlement:
Rejection of Claim due to untrue and incorrect
statements, misrepresentation etc.
9.
Date of receipt of the Complaint:
02/11/2020
10.
Nature of complaint:
Rejection of claim
11.
Amount of Claim:
Rs. 217215
12.
Insurance Ombudsman Rule
(IOR)2017 under which the
Complaint was registered:
Rule 13 1 (b)
13.
Date of hearing/Place:
10/11/2020 Online
14.
Representation at the hearing
m. For the Complainant
Himself
n. For the Insurer
Mr.Karan Bagdai; Dr.Pankaj Srivastava
15
Complaint how disposed
Dismissal
16
Date of Award:
25-11-2020
Contentions of the Complainant:-
The complainant was covered under Group Mediclaim policy of RI. Due to high grade fever with
chills and coughing for 3-4 days, he was admitted at Chinmay Hospital, Jalgaon, on 31/07/2020.
He was diagnosed to have corona, with B/L Pneumonitis. He was in very critical health condition
and hence kept in ICU. The claim has been submitted for reimbursement of total expenses
incurred as Rs. 217215 including the hospitalization expenses of 133100. But the claim was
rejected by RI on the grounds of misrepresentation and untrue, incorrect statements. Hence the
complaint.
Contentions of the Respondent Insurer(RI):-
They have stated in their SCN that the complainant (Mr. Kishor Mahajan) was covered under
Group Health insurance policy taken by 3I Infotech Limited from ICICI Lombard GIC Ltd.
‘On perusal of the hospitalization documents, it was observed that the complainant came with the
complaints of fever, cough and body ache and got hospitalized on July 31, 2020. Thereafter he
was diagnosed with Covid positive and was discharged as DAMA (Discharge against Medical
Advice) on August 08, 2020 and was advised for 10 days quarantine period. During the
investigation, their team visited hospital, verified IPD register, bill records, form-C and ICP papers
were also collected. They found discrepancies in the claim are reproduced below:
d. The hospital had charged visiting fees for three doctors however, as per the available
medical documents, noting, notes of Dr. Sonali Mahajan and Dr. Suyog Choudhari were not
available in ICP papers. We would like to highlight that overwriting were observed on
medical readings for the last three days of hospitalization.
e. Interestingly the last three days TPR chart was adjusted on a single page which is unlike the
pattern followed for rest of the days of admission.
f. The complainant had given written statement confirming that he had only paid Rs.90,000/-
towards hospitalization expenses. We would also like to highlight that for such a huge
hospitalization bill, the mode of payment was cash.
g. From, the available nursing notes of August 05, 2020 signed by Shital states that the
complainant was shifted to general ward however charges applied in the bill were of a
single isolation ward. We hereby enclose the investigation report as Annexure-‘D’ for your
ready reference.
We would like to submit from the above submissions that the complainant has not approached
this Hon’ble Forum with clean hands and has concealed the material facts from the Hon’ble
Forum to cause wrongful gain to herself and wrongful loss to the Company. As the Company
observed a fraudulent activity, the policy was treated as null and void and the claim of the
complainant was not entertained. We wish to submit the relevant clause of the policy schedule
for your reference: Part III of the Policy: Standard terms and conditions applicable to group
benefits
c. Incontestability and Duty of Disclosure The policy shall be null and void and no benefit
shall be payable in the event of untrue or incorrect statements, misrepresentation,
misdescription or on non-disclosure in any material particular in the proposal form,
personal statement, declaration and connected documents, or any material
information having been withheld, or a claim being fraudulent or any fraudulent means
or devices being used by the Insured or any one acting on his behalf to obtain any
benefit under this policy. 8. Fraudulent Claims If any claim is in any respect fraudulent,
or if any false statement, or declaration is made or used in support thereof, or if any
fraudulent means or devices are used by the Insured or anyone acting on his behalf to
obtain any benefit under this policy, or if a claim is made and rejected and no court
action or suit is commenced within twelve months after such rejection or, in case of
arbitration taking place as provided therein, within twelve (12) calendar months after
the Arbitrator or Arbitrators have made their award, all benefits under this policy shall
be forfeited.
Thereafter the claim of the complainant was rejected by the Company and the same was
communicated vide rejection letter dated October 16, 2020. The copy of Rejection Letter is
enclosed herewith as Annexure-‘E’ for your ready reference. In the light of above submissions,
it is therefore submitted that the claim is not payable and the Hon'ble Ombudsman may be
pleased to absolve us of the liability. ‘
Result of personal hearing with both the parties (Observations & Conclusions):
During the personal hearing on 10/11/2020 (through video-conferencing) both the parties
reiterated their stand.
In the instant case, RI has repudiated the claim on grounds of fraud. The forum needs to evaluate
the complaint and evaluate the genuineness of the claim.
a. During the hearing, RI informed that the complainant tried to bribe the investigator also,
who had visited his house in respect of this claim. Complainant agreed to the fact.
b. Complainant had approached this forum with the contention that it was just a coincidence
that the treating doctor was named as Mahajan and by which the RI inferred that is his
relative. From the investigation report submitted by the RI, it is observed that the
complainant has given in writing that the said doctor is his relative and actually he was
given hospital bill upto 6
th
August and have collected Rs.90,000/- only from him. But as the
doctor is his relative, he asked the doctor to issue him bill of enhanced amount. The forum
verified the video recording sent by RI and confirmed their contention. It is seen by the
forum that the complainant was trying to bribe the investigator to make one bill of
injection costing Rs.40,000/- as payable for which he was not having a proper receipt .
c. Forum appreciates that the Investigator has done a good job and also RI’s efforts to curb
the malpractices. In view of this, the RI should black list the said doctor and his hospital
also. RI has acted correctly as per the policy terms and conditions. Award follows:
AWARD
Forum finds that there is no need to intervene in the decision taken by RI in this
matter. Complaint is thus dismissed.
Dated: On 25
th
day of November, 2020 Pune
VINAY SAH
INSURANCE OMBUDSMAN
PUNE.
PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, PUNE
(STATE OF MAHARASHTRA EXCEPT MUMBAI METRO)
UNDER SECTION 17 OF THE INSURANCE OMBUDSMAN RULES-2017
OMBUDSMAN– SHRI VINAY SAH
CASE OF MR.Rajendra Mohite v/s The National Insurance Company Ltd.
COMPLAINT NO: PUN-G-048-1819-0288
Award No IO/PUN/A/GI/ /2020-21
1.
Name & Address of the
Complainant
Mr. Rajendra Prakash Mohite
Navi Mumbai
2.
Policy No:
Type of Policy:
602100/50/16/10002571
Tailormade Group Mediclaim Policy
3.
Policy period:
23/02/2017 to 22/02/2018
4.
Sum Insured
Rs.29,37,00,000/- (Total SI)
5.
Date of inception of first policy:
Not given
6.
Name and age of the Complainant
Name of the Policyholder:
Rajendra P. Mohite Age-27
Rajendra P. Mohite
7.
Name of the Insurer:
National Insurance Co. ltd
8.
Reason for repudiation/Partial
Settlement:
Treatment can be taken on OPD basis
9.
Date of receipt of the Complaint:
25/7/2018
10.
Nature of complaint:
Total Repudiation of letter
11.
Amount of Claim:
Rs. 3,17,892/-
12.
Insurance Ombudsman Rule
(IOR)2017 under which the
Complaint was registered:
13 1(b)
13.
Date of hearing/Place:
10/11/2020 Online
14.
Representation at the hearing
o. For the Complainant:
Insured himself
p. For the insurer:
Mr. Prashant Jadhav
15.
Complaint how disposed:
Allowed
Contentions of the Complainant:
The Complainant was covered under Tailor-made Group Policy issued by RI (Respondent Insurer)
to the Employer Omkar Realtor &Developers Pvt. Ltd. The Complainant was having problem of
Acute PID and Sacrolitis hence admitted in Dr. Mahajan’s Hospital and Industrial Trauma Centre,
Navi Mumbai on 10/11/2017 to 13/11/2017.
As per complaint and his mail correspondence, it is observed that he was having back pain since 6
months before the hospitalization. On the day of hospitalization, condition of the complainant
was so bad that he was not even able to walk or stand due to severe back pain. Hence, he was
admitted in Dr. Mahajan Hospital & undergone a treatment for Acute PID. The Complainant has
submitted bills for reimbursement claim. However, after submission of sufficient proof also
TPA/RI has rejected the claim stating the reason that there was no necessity for hospitalization
and the treatment was possible on day care basis.
As per certificate given by treating doctor, patient/ complainant was not even able to stand
because of severe pain, hence advised to be hospitalized and epidural block procedure done with
injection Depo-metral in both SI Joint under the guidance of C-Arm machine in MOT. Patient was
unable to lie in any position due to severe pain, short general anesthesia was given to patient so
that he could tolerate the procedure. Patient had also been given hormone treatment for general
improvement of health. Patient was further hospitalized for physiotherapy and rehabilitation
program. However, claim was rejected by the RI giving reason that treatment could have been
taken on OPD basis. Hence, the complainant has filed complaint with this Forum for resolution.
Contentions of the Respondent Insurer (RI):
RI has rejected the claim stating that clause 1 –hospitalization is not justifiable and clause 2.6 –
procedure not listed in daycare list. Discharge summary, Indoor Case Papers submitted / retrieved
in the documents indicate that patient was given epidural injection for prolapsed intervertebral
disc. The RI have given their Medical opinion that the insured patient was admitted with
complaints of Lumbar pain on 10/11/2017 at Dr. Mahajan’s Hospital and Industrial Trauma Centre
and was diagnosed with Acute PID and Sacroilitis. The submitted documents indicate oral
medicines, Instraspinal / Intrathecal injections were administered. The claim was denied under
clause 1,2.6 of the policy;
Further, the insured patient has not opted for cashless claim inspite of the hospital being under
TPA Network and though the procedure does not require any Intensive Care, ICU charges have
been shown in the Hospital Bill. The hospital service charges amounting to Rs.25,000/- has been
charged without any justification. RI has also stated that the OT assistant charges are more than
Asst. Surgeon charges. The RI have also mentioned that Test Reports / Investigation Reports
supporting the diagnosis was not available which is mandatory for claim processing. The amount
of bill is found to be on the higher side and items billed have no relevance to the procedure the
patient has undergone. Hence the claim is being denied under clause no. 1.2.6 of the policy.
Result of personal hearing with both the parties (Observations & Conclusions):
During the personal hearing on 10/11/2020 (Online) both the parties reiterated their respective
stand.
From the available documents it is noted that:
b. Despite repeated reminders, the RI has not submitted their SCN to the forum;
c. The Discharge Summary confirms that the insured patient was admitted with
complaints of severe pain in back with numbness in both lower limbs for treatment of
Acute PIVD Sacroiliac Joint Pain. The operation notes confirms that epidural block
procedure done with injection Depo-metral in both SI Joint under the guidance of C-
Arm machine in MOT.
d. The RI has rejected the claim on the grounds that the treatment could have been taken
on OPD basis. The RI have investigated the hospitalization and have found various
discrepancies. During the hearing, the complainant could not give convincing replies to
the objections raised by RI.
e. The forum finds from the available documents that as the insured patient was in pain
during his admission to the treating hospital and hence all the treatment administered
to the patient on the first day can be considered for payment. As per the document /
hospital bill submitted, the following charges are payable:
Particulars
Amount (Rs.)
1 day Hospital stay
3,500/-
Consultation
1,500/-
ICU charges
6,500/-
Nursing charges
1,000/-
Visit charges of 3 Doctors
2,150/-
Medicines purchased on 10/11/17
16,275/-
Total Rs….
23,813/-
The Forum feels that total rejection of the claim by the RI is not in order and the complaint
is allowed as per calculations given above.
Award follows:
AWARD
Under the facts and circumstances, the RI is directed to pay Rs.23,813/- towards full and final
settlement of the complaint adhering to the following rules of IOR 2017.
The award is to be settled within one month from the date of receipt of this award failing which
it will attract interest at the prevailing bank rate plus 2% extra from the date of rejection of the
claim till the date of payment of this award.
The attention of the Complainant and the Insurer is hereby invited to the following provisions of
Insurance Ombudsman Rules 2017:
17(6) the insurer shall comply with the award within thirty days of the receipt of the award and
intimate compliance of the same to the Ombudsman.
17(8) the award of Insurance Ombudsman shall be binding on the insurers.
Dated: at Pune this 26
th
day of February 2021
VINAY SAH
Insurance Ombudsman, Pune
PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, PUNE
(STATE OF MAHARASHTRA EXCEPT MUMBAI METRO)
UNDER SECTION 16/17 OF THE INSURANCE OMBUDSMAN RULES-2017
OMBUDSMAN–VINAY SAH
CASE OF Mr. Rajkumar Pawar Vs. The Oriental Insurance Company Ltd.
COMPLAINT NO: PUN-G-050-1819-0559
Award No IO/PUN/A/GI/ /2020-2021
1.
Name & Address of the
Complainant
Mr. Rajkumar Pawar
Annapurna Nivas, Sonai Nagar, Nr. Sambhaji
Chowk,
Canal Road, Nanded – 431605 (M.S.)
2.
Policy No:
Type of Policy:
163600/48/2018/8808
Group Tailormade Mediclaim Insurance
(MSEDCL)
3.
Policy period:
15/02/2018 to 14/02/2019
4.
Sum Insured/IDV
Rs.25166100000 (Group Sum Insured)
5.
Date of inception of first policy:
Continuous Renewal (Group Policy)
6.
Name & age of the Insured:
Name of the Policyholder:
Master Rohith Rajkumar Pawar;Age: 10 yrs
MSEDCL
7.
Name of the Insurer:
The Oriental Insurance Company Ltd.
8.
Reason for rejection /Partial Settlement:
Partial claim settlement denying expenses
for cochlear implant
9.
Date of receipt of the Complaint:
29/01/2019
10.
Nature of complaint:
Partial payment of health claim
11.
Amount of Claim:
Rs.13,74,797/-
12.
Rule of IOR 2017 under which the
Complaint was registered:
13(1)(b)
13.
Date of hearing/Place:
06/11/2020 (Online)
14.
Representation at the hearing
q. For the Complainant:
Insured himself
r. For the insurer:
Mrs. Sunita Bhurewar
15.
Complaint how disposed:
Allowed
Contentions of the Complainant:
Complainant and his family were insured with the Respondent Insurer (RI) under the above policy
for the period 15/02/2018 to 14/02/2019. The insured patient aged 10 years was admitted to
MAA Hospitals Ltd., Hyderabad with complaints of Bil hard of hearing since age 2 years and was
diagnosed as Bil profound hearing loss. The patient was treated for Rt. Cochlear implantation
with laser. The claim was partially rejected by the RI on the grounds that the claim has been
settled as per reasonable and customary charges and by denying the cost of cochlear implant
considering it as hearing aid excluded from the policy cover.
After the claim documents of the insured patient, were submitted to the RI for reimbursement,
the RI after going through the records, settled the claim for Rs.81,900/- out of total hospitalization
bill of Rs14,56,697/- stating that the claim has been settled as per terms and conditions of the
policy.
The complainant has stated that the insured patient was suffering from hearing loss and after
admission, they were given a cashless authorization for Rs.1,01,250/- against an estimate of
Rs.15,15,000/-. The complainant has stated that the cost of implant was not approved by the TPA
/ RI costing around Rs.13,65,000/-. Due to delay in the approval, the surgery was even postponed
to enable the RI to approve the amount towards cost of implant.
The policy details provided by him are:
c. Regular Policy: 163600/48/18/08808 having SI of Rs.3 lakhs
d. Compulsory Top up policy: 163600/48/18/08949 SI of Rs.2 lakhs
e. Additional Employee Top up: 163600/48/19/00695 of Rs.10 lakhs
He has further contended that stent cost in a heart surgery is paid in the policy then why not a
cochlear implant. He has contended that a cochlear implant is not hearing aid but an implant. He
has also provided in detail write up on how a cochlear implant differs from hearing aid and
insisted for granting payment for the cochlear implant.
The complainant has approached the Grievance Cell of the RI and they have replied that the
Company is rejecting his partial claim as hearing aids are excluded and not covered under the
terms and conditions of the policy.
The claims have not been settled by the RI till date and aggrieved with this situation; the
complainant has approached the forum for the resolution of his grievance.
Contentions of the Respondent Insurer (RI):
The rejection of payment for cochlear implant is based on the policy exclusion No.4.6 reproduced
below:
Clause 4.6 - Surgery for correction of eye sight cost of spectacles, contact lenses, hearing aids
etc.
Claim status:
The requested amount Rs.14,56,697
Claim Type-Cashless
Status-claim has been paid
For the liability amount Rs.81900/-
Result of personal hearing with both the parties (Observations & Conclusions):
During the personal hearing on 06/11/2020 (Online), both the parties reiterated their respective
stand. During hearing, the RI was not able to answer the questions as to –
Why expert’s opinion was not processed on priority basis
Whether the implant is excluded under the terms and conditions of the group policy? The
implant is internally fixed unlike hearing aid which is external;
During hearing, the RI / TPA assured the forum that they would be submitting an
Independent Report / Opinion from a Medical Professional substantiating their stand of
repudiation, but they have not been able to do so till date.
The dispute here can be resolved by getting clarification on the point whether the cochlear
implant falls under the category of hearing aid or not. The major differences / aspects between
the hearing aid and a cochlear implant can be summarized as follows:
Hearing aids amplify acoustic sound generally and/or by specific frequencies. A cochlear
implant device allows you to hear in a different way. ... It translates acoustic sound into
electrical signals. It sends the signals directly to the hearing nerve and then on to the brain.
Hearing aids are the instrument of choice for the majority of people with hearing loss, but for
those who are deaf or severely hard of hearing; cochlear implants may be a better option.
Both hearing aids and cochlear implants work best for people diagnosed with sensor neural
hearing loss, meaning they have damage to the hair cells in the inner ear and/or the nerve
pathways from the inner ear to the brain.
Cochlear implants are surgically implanted by a surgical specialist. They stimulate the
auditory nerve to provide the sensation of sound for those who are deaf or severely hard of
hearing. Hearing aids are removable and are used to amplify sound for people with residual
hearing. They are taken in and out of the ear canal by the user.
Hearing aids are removable whereas the cochlear implant kit cannot be removed as a part of
the unit is implanted.
Cochlear implants look similar to hearing aids but require surgical implantation. Cochlear
implants are complex medical devices which must be surgically implanted by a medical
professional. These devices bypass the damaged portion of the inner ear to directly stimulate
the auditory nerve. Cochlear implants do not restore hearing, rather, they provide the
sensation of sound for those who are deaf or have profound hearing loss.
There are two main parts to a cochlear implant: external and internal:
To be more assured on the above observations, this forum took an expert’s opinion from a
renowned ENT specialist and surgeon in cochlear implant. The same is reproduced below:
‘The Cochlear implant is an electronic device which has two parts!
Internal part needs to be fitted by performing Cochlear implant surgery.
Outside part has sound processor and battery, which the person starts wearing after 15days after
the surgery
There are 4 companies which are available in the world which are approved and as all these are
from other countries we get implants thorough their dealers
The basic implant cost is 6,09,000/- and the highest quality one is 15-16 lacs.’
The doctor further informed that the cost of medium type of implant is a combination of good
quality internal component with basic quality of external component. This amounts to Rs. 8 to 9
lacs approximately.
In view of the expert’s opinion, it is clarified that cochlear implant is not a hearing aid in the literal sense
though it is an instrument which aids hearing, but it is an implant for which the policy does not have an
exclusion. Therefore, the complainant is entitled to get the cochlear implant expenses upto Rs.8 lacs at
least, which is a medium quality implant. As the policy is subjected to the reasonability and customary
clause, the amount is restricted to Rs.8 lacs over and above the surgery expenses already paid by the RI. In
view of the Top up cover and additional employee top up cover mentioned above, the amount seems
admissible under the consolidation of above policies. The complaint is allowed. Award follows:
AWARD
Under the facts and circumstances, the RI is directed to pay Rs.8,00,000/- or maximum up to the
consolidated amounts of sum insured (whichever is less) under various policies available for the
complainant in the respective policy year, towards full and final settlement of the complaint
adhering to the following rules of IOR 2017.
The award is to be settled within one month from the date of receipt of this award failing which
it will attract interest at the prevailing bank rate plus 2% extra from the date of rejection of the
claim till the date of payment of this award.
The attention of the Complainant and the Insurer is hereby invited to the following provisions of
Insurance Ombudsman Rules 2017:
17(6) the insurer shall comply with the award within thirty days of the receipt of the award and
intimate compliance of the same to the Ombudsman.
17(8) the award of Insurance Ombudsman shall be binding on the insurers.
Dated: at Pune, this 25
th
day of February 2021
VINAY SAH
Insurance Ombudsman, Pune
PROCEEDINGS BEFORE
THE INSURANCE OMBUDSMAN, STATE OF RAJASTHAN
UNDER THE INSURANCE OMBUDSMAN RULES, 2017
OMBUDSMAN – MS. SANDHYA BALIGA
CASE OF AJAY KUMAR SAHANI V/S UNITED INDIA INSURANCE CO.LTD
COMPLAINT REF: NO JPR-H-051-2021-0173
AWARD No. IO/JPR/H/A/2021/000
1.
Name & Address of the Complainant
Shri Ajay Kumar Sahani,
D-1/14, Secondary School Road, Pratap
Nagar, Bhilwara
2.
Policy No:
Type of Policy
Commencement of the Risk /Policy
period
5001002819P111087388
Group Health Insurance (Union Bank of
India employees)
01.10.2019 to 30.09.2020 S.I. : Rs. 3 lacs
3.
Name of the insured
Name of the policyholder
Shri Ajay Kumar Sahani
Shri Ajay Kumar Sahani
4.
Name of the insurer
United India Insurance Company Ltd
5.
Date of Repudiation/query
01.08.2020
6.
Reason for repudiation
Claim partially settled due to non
submission of documents under
mediclaim
7.
Date of receipt of the Complaint
14.12.2020
8.
Nature of complaint
Partial settlement of the health claim
9.
Amount of Claim
Rs. 37871/-
10.
Date of Partial Settlement
Rs.15620/-
11.
Amount of relief sought
Rs. 22251/-
12.
Complaint registered under
Rule no: of IOB rules
13(1) (b)
13.
Date of hearing/place
21.01.2021/through video conferencing
GoTOMeeting app
14.
Representation at the hearing
v. For the
Complainant
Shri Ajay Kumar Sahni
vi. For the insurer
Ms. Pamela Pinto, Dy. Manager
15
Complaint how disposed
Award
16
Date of Award/Order
25.01.2021
17). Brief fact of the case : Shri Ajay Kumar Sahani (herein after referred to as the
complainant) had filed a complaint against the decision of United India Insurance Company
Ltd (herein after referred to as respondent Insurance Company) alleging partial settlement
of mediclaim under Group Health Insurance policy no. 5001002818P111087388.
18) Cause of Complaint:
Complainant’s argument: The complainant stated that he had insurance coverage under group
health insurance policy taken by his employer (Union Bank of India) from Respondent insurance
company with risk commencement from 01.10.2019 to 30.09.2020. The insured was admitted in
Ram snehi Chikitsalaya, Bhilwara with diagnosis of Acute Pancreatitis on 01.01.2020 and got
discharged on 05.01.2020 after treatment. After discharge from the hospital, he submitted the claim
of treatment taken by him for reimbursement to the Insurance Company vide claim no.
HH872054276 for Rs. 37871 on 18.02.2020 alongwith the original bills, reports, receipts and
prescriptions. The TPA raised query on 24.02.2020 seeking additional documents. The complainant
replied that all the documents have already been submitted. However, he again sent photocopies of
all the requirements to TPA. He made various communications to the customer care of TPA
through email or phone and on 22.07.2020 he received an SMS from TPA informing that all the
required documents have been received and the claim is being processed. On 01.08.2020 the
insurance company partially settled his claim for Rs. 15620 out of Rs. 37871/- without mentioning
any reason of deduction. The complainant approached GRO on 04.08.2020 for settlement of
balance amount of the Mediclaim. But the Insurance Company did not respond. Complainant did
not get any response from GRO of the Insurance Company. Being aggrieved complainant
approached this forum for redressal of his grievance.
Insurers’ argument:- The Insurance Company in its SCN dated 13.01.2021 submitted that Insured
had taken a policy under group Mediclaim of Union Bank Employee. Since the TPA received the
documents for Rs. 16120/- only, and the claim settled by the Insurance Company for Rs. 15620/-.
Hence the Insurance Company settled the claim in accordance with the terms and conditions of the
policy.
19) Reason for Registration of Complaint: Partial Settlement of mediclaim under health insurance
policy.
20) The following documents were placed for perusal.
s. Complaint letter
t. Copies of documents submitted by the complainant
u. Form VI A duly signed by the complainant.
v. SCN and a form VIIA duly signed by the Insurance Company
21) Result of hearing with both parties (Observations and Conclusion) :- I heard both the
sides, the complainant and the Insurance Company through video conferencing on 21.01.2021. The
complainant reiterated that he had already submitted all the relevant documents and bills to the
Insurance Company and repeatedly been complying the queries raised by the Insurance Company,
but the claim had been settled by the Insurance company partially only for the bills, which were
acknowledged by TPA. The Insurance company stated that they have already settled the claim of
Rs. 15620 for the bills received by them out for Rs. 16120, the remaining claim amount of Rs.
21751/- were non-admissible on account of non submission of the bills and receipts. It was further
added by insurer that if these duplicate bills (certified bills), which were missing and not received
by the company would be settled as and when submitted by the complainant. The Insurance
Company provided the office address to the complainant to submit the bill to the Insurance
Company directly for its settlement.
On perusal of the documents exhibited and oral submissions made during the hearing, I find that
the Insurance Company was ready to settle the claim on receipt of the relevant documents. Hence
the complainant is directed to submit the certified copy of the relevant bills alongwith affidavit.
Accordingly an Award is passed with a direction to the Insurance Company to settle the claim to
the insured on receipt of certified copy of the bills as admissible.
22. The attention of the Complainant and the Insurer is hereby invited to the following provisions
of Insurance Ombudsman Rules, 2017:
12. According to Rule 17(5) of Insurance Ombudsman Rules, 2017, a copy of the award
shall be sent to the complainant and the insurer named in the complainant.
13. As per Rule 17(6) of Insurance Ombudsman Rules, 2017, the insurer shall comply with
the award within 30 days of the receipt of the award and intimate compliance of the
same to the Ombudsman.
Place: Jaipur SANDHYA BALIGA
Dated: 25.01.2021 INSURANCE OMBUDSMAN
AWARD
Taking into account the facts and circumstances of the case and the submissions
made by both the parties during the course of hearing, the Insurance Company is
directed to settle the claim to the insured on receipt of certified copies of bills and
receipt, as admissible .
PROCEEDINGS BEFORE
THE INSURANCE OMBUDSMAN, STATE OF RAJASTHAN
UNDER THE INSURANCE OMBUDSMAN RULES, 2017
OMBUDSMAN – MS. SANDHYA BALIGA
CASE OF SH HARI CHARAN SHARMA V/S UNITED INDIA INSURANCE CO.LTD
COMPLAINT REF: NO JPR-H-051-2021-0179
AWARD No. IO/JPR/H/A/2021/000
1.
Name & Address of the Complainant
Shri Hari Charan Sharma, 68/27, Pratap
nagar, Jaipur
2.
Policy No:
Type of Policy
Commencement of the Risk /Policy
period Sum Insured
5001002819P112416226 (Group Health
Insurance of SBBJ retired employees)
Group Health Insurance
01.11.2019 to 31.10.2020
Rs. 4 Lacs
3.
Name of the insured
Name of the policyholder
Smt. Shanti Devi Sharma
Shri Hari Charan Sharma
4.
Name of the insurer
United India Insurance Company Ltd
5.
Date of Repudiation
29/10/2020
6.
Reason for repudiation
Partial repudiation of claim
7.
Date of receipt of the Complaint
03.12.2020
8.
Nature of complaint
Partial repudiation of mediclaim
9.
Amount of Claim
Rs. 592913/-
10.
Date of Partial Settlement
Rs. 294477/- on 29.10.2020
11.
Amount of relief sought
Rs. 298436/-
12.
Complaint registered under
Rule no: of IOB rules
13(1) (b)
13.
Date of hearing/place
20.01.2021/ Jaipur through GoTo Meeting
14.
Representation at the hearing
g. For the Complainant
Shri T.N.Sharma, Son
h. For the insurer
Ms. Pamela Pinto, Dy. Manager
15
Complaint how disposed
Award
16
Date of Award/Order
28.01.2021
17). Brief fact of the case : Shri Hari Charan Sharma (herein after referred to as the
complainant) had filed a complaint against the decision of United India Insurance Company
Ltd (herein after referred to as respondent Insurance Company) alleging partial settlement
of mediclaim under Group Health Insurance policy no. 5001002819P112416226.
18) Cause of Complaint:
Complainant’s argument: The complainant stated that he was under coverage of group health
insurance policy for Sum insured of Rs. 400000/- from Respondent insurance company with risk
commencement from 01.11.2019 to 31.10.2020 alongwith his wife. The Complainant’s wife
(Insured) was admitted in the Mahavir Jaipuria Rajasthan Hospital, Jaipur on 04.08.2020 and
diagnosed Covid-19. She underwent treatment of COVID-19 and passed away on 02.09.2020. After
death of the insured, the complainant submitted the mediclaim to the Insurance Company for
reimbursement of the expenses incurred of Rs. 592913/-. But the claim was partially settled on
29.10.2020 for Rs. 294477 by the insurance company and remaining claim for Rs.298436 rejected
being non payable towards laboratory charges, medicine and radiology charges as per the terms and
conditions of the policy. Hence he again approached GRO on 29.10.2020 for reconsidering the
Mediclaim, but the Insurance Company did not respond to his representation. Being aggrieved
complainant approached this forum for redressal of his grievance.
Insurers’ argument:- The Insurance Company in its SCN dated 13.01.2021 submitted that the
patient was admitted for Covid 19, Pneumonia, Respiratory Failure, septic shock, MOFS, type 2
DM, Hypertension. The claim was settled by the Insurance Company on the terms and conditions
of the policy. In view of the increasing number of Covid 19 claims, GI council had set up a
committee comprising of Insurers, TPA for standardization of rates for treatment of Covid 19.
Wherever the Covid-19 treatment charges have been published by any Government Authority,
those charges were applicable to insurance claims subject to the policy terms and conditions. The
inclusions in the Covid package charges are consultation, nursing charges, room stay and meals ,
covid testing, monitoring and investigations – Biochem & Imaging, physiotherapy, PPE, drugs and
medical consumables, biochemical waste management and other protective gears, bed side
procedures like ryles tube insertion, urinary tract catheterization. Since the hospital had charged
covid package at Rs. 90000, the insurance company disallowed the cost of medicines (except for
high end drugs) and Laboratory charges. The Respondent, therefore, repudiated the claim in
accordance with the terms and condition of the policy.
19) Reason for Registration of Complaint: Partial Settlement of mediclaim under health insurance
policy.
20) The following documents were placed for perusal.
o Complaint letter
o Copies of documents submitted by the complainant
o Form VI A duly signed by the complainant.
o SCN and a form VIIA duly signed by the Insurance Company
21)Result of hearing with both parties (Observations and Conclusion) :- :- I heard both the
sides, the complainant (represented by his son) and the Insurance Company through video
conferencing on 20.01.2021. The complainant submitted that the insurance company did not
correctly settle the claim of COVID-19 disease treatment as per the guidelines issued by the Health
Department, Govt. of Rajasthan on 20.06.2020, wherein the inclusion and exclusion details in the
covid package have been given. The Insurance Company stated that the claim was settled on the
rates decided by GI council committee set up for standardization of rates for treatment of Covid -
19, which was as per the terms and condition of the policy.
On perusal of the documents exhibited and oral submissions made, I find that the GI council rates
circular was the internal letter of the insurance company and it was not brought to the notice of the
complainant. As per the guidelines notified by Medical and health Department, Govt. of Rajasthan,
Jaipur dated 20.06.2020 clearly mention the inclusion and exclusions of the Covid-19 package.
Medicines, investigation reports and isolations room are not part of the package, hence these are
payable. Therefore, I direct the Insurance Company to settle the claim, as admissible minus the
claim amount already paid.
Accordingly, an Award is passed with a direction to the Insurance Company to settle the claim of
the insured, as admissible minus claim amount already paid.
22. The attention of the Complainant and the Insurer is hereby invited to the following provisions
of Insurance Ombudsman Rules, 2017:
f) According to Rule 17(5) of Insurance Ombudsman Rules, 2017, a copy of the award shall be
sent to the complainant and the insurer named in the complainant.
AWARD
Taking into account the facts and circumstances of the case and the submissions made by both
the parties during the course of hearing, the Insurance Company is directed to settle the claim
to the insured, as admissible minus claim amount already paid.
g) As per Rule 17(6) of Insurance Ombudsman Rules, 2017, the insurer shall comply with the
award within 30 days of the receipt of the award and intimate compliance of the same to the
Ombudsman.
Place: Jaipur SANDHYA BALIGA
Dated: 28.01.2021 INSURANCE OMBUDSMAN
PROCEEDINGS BEFORE
THE INSURANCE OMBUDSMAN, STATE OF RAJASTHAN
UNDER THE INSURANCE OMBUDSMAN RULES, 2017
OMBUDSMAN – MS. SANDHYA BALIGA
CASE OF LEKHRAJ MEENA V/S UNITED INDIA INSURANCE CO.LTD
COMPLAINT REF: NO JPR-H-051-2021-0188
AWARD No. IO/JPR/H/A/2021/000
1.
Name & Address of the Complainant
Shri Lekhraj Meena
C-339, Talwani, Kota
2.
Policy No:
Type of Policy
Commencement of the Risk /Policy
period Sum Insured
5001002819P109951263
Group Health Insurance (Central Bank of
India employees)
01.10.2018 to 30.09.2019
Rs. 3 Lacs
3.
Name of the insured
Name of the policyholder
Smt.Sheela Meena, Wife
Shri Lekhraj Meena
4.
Name of the insurer
United India Insurance Company Ltd
5.
Date of Repudiation
17.08.2020
6.
Reason for repudiation
Full repudiation of claim for delayed
submission as per clause no.2.32
7.
Date of receipt of the Complaint
04.12.2020
8.
Nature of complaint
Full repudiation of mediclaim
9.
Amount of Claim
Rs.1134592/-
10.
Date of Partial Settlement
N.A.
11.
Amount of relief sought
Rs. 1134592/-
12.
Complaint registered under
Rule no: of IOB rules
13(1) (b)
13.
Date of hearing/place
20.01.2021/ Jaipur through GoToMeeting
video conferencing
14.
Representation at the hearing
i. For the Complainant
Shri Lekhraj Meena
j. For the insurer
Ms. Pamela Pinto, Dy. Manager
15
Complaint how disposed
Award
16
Date of Award/Order
25.01.2021
17). Brief fact of the case : Shri Lekhraj Meena (herein after referred to as the complainant) had filed a
complaint against the decision of United India Insurance Company Ltd (herein after referred to as
respondent Insurance Company) alleging repudiation of his mediclaim under group Health Insurance policy
no. 5001002819P109951263.
18) Cause of Complaint:
Complainant’s argument: The complainant stated that he had taken group health insurance policy for Sum
insured of Rs. 300000/- from Respondent insurance company with risk commencement date from
01.10.2018 to 30.09.2019 covering his wife Smt. Sheela Meena. The Insured Smt. Sheela Meena,
(Complainant’s wife) was diagnosed and treated for pregnancy IUD, LSCS Eclampsia with hypertensive
sepsis, multiple organ failure syndrome, stress, Ulcer, GI bleeding, severe anemia and chronic hypertension.
She got admitted in Fortis Hospital, Jaipur for her treatment on 22.09.2019 and discharged from the hospital
on 10.10.2019. After discharge from the hospital, he had submitted mediclaim to the employer on
10.11.2019 for Rs. 459165 for reimbursement, which was collected by the Insurance Company on
25.11.2019 under claim no. 0030995671. On 17.08.2020 the Insurance Company repudiated the mediclaim
on the ground of delayed submission of the documents as per clause no. 2.32 of the policy. He approached
GRO on 05.10.2020 for reconsideration of settlement of claim. But, no response was given by the Insurance
Company. Being aggrieved complainant approached this forum for redressal of his grievance.
Insurer’s argument:- The Insurance Company in its SCN dated 13.01.2021 submitted that the
patient was not covered under the policy no.5001002818P109951263 for the period from
1.10.2018 to 30.09.2019. The official request for addition of Mrs. Sheela was made on 29.01.2020
i.e. 4 months after the expiry of the policy on 30.09.2019. On receiving request for addition of Mrs.
Sheela, Insurance Company granted cover under policy no. 5001002819P111074041 for the period
from 01.10.2019 to 30.09.2020. As the hospitalization of Mrs. Sheela from 20.09.2019 to
10.10.2019 falls under policy period from 01.10.2018 to 30.09.2019 and since she was not covered
during this period of insurance (Policy no. 5001002818P109951263), the insurance company
repudiated the claim. Further, the claim was submitted by the Complainant to the Insurance
company on 25.11.2019, whereas the last date for submission of the claim papers in the policy no.
5001002818P109951263 was 15.11.2019 or 30 days of discharge from the hospital. Hence the
claim was also not tenable as per clause 2.32. Therefore the Respondent repudiated the claim in
accordance with the terms and condition of the policy.
19) Reason for Registration of Complaint: Full Repudiaton of mediclaim under health insurance policy.
20) The following documents were placed for perusal.
o Complaint letter
o Copies of documents submitted by the complainant
o Form VI A duly signed by the complainant.
o SCN and a form VIIA duly signed by the Insurance Company
21 Result of hearing with both parties (Observations and Conclusion) :- I heard both the sides,
the complainant and the Insurance Company. The complainant submitted that he had submitted mediclaim
papers to his employer on 10.11.2019, within the time limit. But the same were collected by the
representative of TPA on 26.11.2019. But the Insurance company repudiated on the ground of delay
submission. The Insurance Company submitted that the claim submitted by the complainant was wrongly
repudiated on the ground of delay submission. After registration of complaint with Bima Lokpal, the
insurance company reviewed the case and it was found that the patient was not insured during the
hospitalization period in the given policy. Therefore the claim was non payable due to ineligibility. The
Complainant submitted that her wife was covered in the policy at the time of hospitalization. Earlier this
query was raised by the insurance company, which was replied by complainant on 16.06.2020 stating that
she was added in HRMS on 30.11.2018 as dependent under ID issued by TPA MD India as MDI-5-
0030995671. Hence the insurance company made false statement regarding ineligibility.
On perusal of the documents exhibited and oral submissions made, I find that the Complainant had
submitted the claim papers to the employer well within the time. However, the same were collected by the
TPA late i.e. after close of policy period, for which the complaint should not be held responsible. The
insurance company had raised the issue of ineligibility at the time of submission of SCN, whereas the
repudiation of the claim was on the ground of delayed submission. Hence the reason of ineligibility could
not be attended at this stage. Therefore, the Insurance Company is directed to decide/re-examine the claim as
admissible. The delay in submission of the claim is condoned .
Accordingly, an Award is passed with a direction to the Insurance Company to decide/re-examine the
claims as admissible condoning the delayed submission of the claims.
22. The attention of the Complainant and the Insurer is hereby invited to the following provisions of
Insurance Ombudsman Rules, 2017:
h) According to Rule 17(5) of Insurance Ombudsman Rules, 2017, a copy of the award shall be sent to the
complainant and the insurer named in the complaint.
i) As per Rule 17(6) of Insurance Ombudsman Rules, 2017, the insurer shall comply with the award within
30 days of the receipt of the award and intimate compliance of the same to the Ombudsman.
Place: Jaipur SANDHYA BALIGA
Dated: 25.01.2021 INSURANCE OMBUDSMAN
AWARD
Taking into account the facts and circumstances of the case and the submissions made by both
the parties during the course of hearing, the Insurance Company is directed to decide/re-
examine the claims as admissible condoning the delayed submission of the claims.
PROCEEDINGS BEFORE
THE INSURANCE OMBUDSMAN, STATE OF RAJASTHAN
UNDER THE INSURANCE OMBUDSMAN RULES, 2017
OMBUDSMAN – MS. SANDHYA BALIGA
CASE OF NARENDRA DALAWAT V/S UNITED INDIA INSURANCE CO.LTD
COMPLAINT REF: NO JPR-H-051-2021-0185
AWARD No. IO/JPR/H/A/2021/000
1.
Name & Address of the Complainant
Shri Narendra Dalawat
4, Bapna House, Hospital Road, Udaipur.
2.
Policy No:
Type of Policy
Commencement of the Risk /Policy
period Sum Insured
2210002818P117394120
Group Health Insurance
31.03.2019 to 30.03.2020
Rs. 2 Lacs
3.
Name of the insured
Name of the policyholder
Smt. Chosar Bai Jain, Mother
Shri Narendra Dalawat
4.
Name of the insurer
United India Insurance Company Ltd
5.
Date of Repudiation
23.07.2020
6.
Reason for repudiation
Partial Settlement of claim on capping rate
7.
Date of receipt of the Complaint
03.12.2020
8.
Nature of complaint
Partial settlement of mediclaim
9.
Amount of Claim
Rs.28800/-
10.
Date of Partial Settlement
Rs. 10000/- (23.07.2020)
11.
Amount of relief sought
Rs. 18800/-
12.
Complaint registered under
Rule no: of IOB rules
13(1) (b)
13.
Date of hearing/place
20.01.2021/ Jaipur through GoToMeeting
video conferencing
14.
Representation at the hearing
k. For the Complainant
Shri Narendra Dalawat
l. For the insurer
Shri Abhijeet Pandey, Dy. Manager
15
Complaint how disposed
Award
16
Date of Award/Order
20.01.2021
17). Brief fact of the case : Shri Narendra Dalawat (herein after referred to as the complainant) had filed a
complaint against the decision of United India Insurance Company Ltd (herein after referred to as
respondent Insurance Company) alleging repudiation of his mediclaim under group Health Insurance policy
no. 2210002818P117394120 (Jain International Organization).
18) Cause of Complaint:
Complainant’s argument: The complainant stated that he had taken group health insurance policy for Sum
insured of Rs. 200000/- from Respondent insurance company with risk commencement from 31.03.2019 to
30.03.2.2020 covering his mother. The Insured Smt. Chosar Bai Jain, (Complainant’s Mother) was
diagnosed and treated for cataract in Left Eye. She got admitted in Kothari Eye Hospital, Udaipur for
surgery on 18.03.2020 and discharged from the hospital on 19.03.2020. After discharge from the hospital, he
had submitted mediclaim to the Insurance Company under claim no. 201100054685 for Rs. 28800 for
reimbursement. On 23.07.2020 the Insurance Company had partially settled the mediclaim for Rs. 10000
after deduction of Rs. 5000 (towards compulsory deductible) and remaining Rs. 13800 were disallowed on
the ground of reasonable, usual and customary (UCR) clause. He approached GRO on 08.09.2020 for
reconsideration of full settlement of claim. But, no response was given by the Insurance Company. Being
aggrieved complainant approached this forum for redressal of his grievance.
Insurers’ argument:- The Insurance Company in its SCN dated 14.01.2021 submitted that the patient got
hospitalized for cataract operation in Left Eye. As per the policy terms and conditions, cataract limit was
Rs. 15000/- and deductible of Rs. 5000/- was also applicable. Hence the insurance company paid Rs.
10000/-. Hence the Insurance Company had settled the claim in accordance with the terms and conditions
of the policy.
19) Reason for Registration of Complaint: Partial settlement of mediclaim under health insurance policy.
20) The following documents were placed for perusal.
o Complaint letter
o Copies of documents submitted by the complainant
o Form VI A duly signed by the complainant.
o SCN and a form VIIA duly signed by the Insurance Company
21 Result of hearing with both parties (Observations and Conclusion) :- I heard both the sides,
the complainant and the Insurance Company. The complainant submitted that he was having the coverage of
group health insurance taken by Jain International Organization and insurance cover was taken by them from
United India Insurance and Universal Sampo General Insurance for Rs. 2 lacs and 3 lacs respectively. The
United India Insurance Company settled the partial claim submitted by him for cataract operation. The
insurance company submitted that the claim had been rightly settled as per the terms and conditions of the
policy. As per the policy terms and conditions, cataract limit was Rs. 15000/- and deductible of Rs. 5000/-
was also applicable. Hence the insurance company paid Rs. 10000/-. The complainant further submitted that
for balance amount of claim, he had to submit the claim papers to Universal Sampo GI company, for which
he required the original bills and treatment related documents.
On perusal of the documents exhibited and oral submissions made during the course of video conferencing, I
find that the insurance company (UIIC) had settled the case as per the permissible limits for cataract under
the policy and to file the balance amount of claim with Universal Sampo, the complainant requires the
original bills and treatment documents. Therefore, the Insurance Company is directed to provide either
original or certified copy of the original bills, claim papers, treatment documents to the complainant for
onward submission of the claim to coinsurer.
Accordingly, an Award is passed with a direction to the Insurance Company to provide original or
certified copy of the original bills, claim papers, treatment documents to the complainant within 10
days.
AWARD
Taking into account the facts and circumstances of the case and the submissions made by both
the parties during the course of hearing, the Insurance Company is directed to provide original
or certified copy of the bills, claim papers and treatment documents to the complainant within
10 days.
22. The attention of the Complainant and the Insurer is hereby invited to the following provisions of
Insurance Ombudsman Rules, 2017:
j) According to Rule 17(5) of Insurance Ombudsman Rules, 2017, a copy of the award shall be sent to the
complainant and the insurer named in the complaint.
k) As per Rule 17(6) of Insurance Ombudsman Rules, 2017, the insurer shall comply with the award within
30 days of the receipt of the award and intimate compliance of the same to the Ombudsman.
Place: Jaipur SANDHYA BALIGA
Dated: 20.01.2021 INSURANCE OMBUDSMAN
PROCEEDINGS BEFORE
THE INSURANCE OMBUDSMAN, STATE OF RAJASTHAN
UNDER THE INSURANCE OMBUDSMAN RULES, 2017
OMBUDSMAN – MS. SANDHYA BALIGA
CASE OF SH RAMESH KUMAR UPADHYAY V/S THE NEW INDIA ASSURANCE CO.LTD
COMPLAINT REF: NO JPR-H-049-2021-0190
AWARD No. IO/JPR/H/A/2021/000
1.
Name & Address of the Complainant
Shri Ramesh Kumar Upadhyay,
16-17, Ranjeet Nagar, Ram Dev Road, Pali
2.
Policy No:
Type of Policy
Commencement of the Risk /Policy
period/Sum Insured
12030034190400000015 (Group Heatlh
Insurance for agents)
Group Health Insurance
01.09.2019 to 31.08.2020
Rs.150000
3.
Name of the insured
Name of the policyholder
Shri Ramesh Kumar Upadhyay
Shri Ramesh Kumar Upadhyay
4.
Name of the insurer
The New India Assurance Company Ltd
5.
Date of Repudiation
Non Settlment
6.
Reason for repudiation
Non settlement of Health claim due to non
submission of query raised
7.
Date of receipt of the Complaint
21.12.2020
8.
Nature of complaint
Non Settlement of Health claim
9.
Amount of Claim
Rs.13148 /-
10.
Date of Partial Settlement
N.A.
11.
Amount of relief sought
Rs. 13148/-
12.
Complaint registered under
Rule no: of IOB rules
13(1) (b)
13.
Date of hearing/place
21.01.2021/ Jaipur through GoToMeeting
video conferencing
14.
Representation at the hearing
i. For the Complainant
Shri Ramesh Kumar Upadhyay
(i) For the insurer
Shri Mahesh Kumar, Dy. Manager
15
Complaint how disposed
Award
16
Date of Award/Order
28.01.2021
17). Brief fact of the case : Shri Ramesh Kumar Updhyay (herein after referred to as the
complainant) had filed a complaint against the decision of The New India Assurance Company Ltd
(herein after referred to as respondent Insurance Company) alleging Non settlement of mediclaim
under Health Insurance policy no. 12030034190400000015.
18) Cause of Complaint:
Complainant’s argument: The complainant stated that he had under coverage of group health
insurance policy bearing no. 12030034190400000015 taken by LIC of India from Respondent
insurance company with risk commencement date from 01.09.2019 to 31.08.2020 for Rs. 1.50
lacs sum Insured. The complainant was admitted in Pali Seva Mandal Hospital, Pali on 02.03.2020
for cataract operation in Left Eye and discharged on the 04.03.2020. The Mediclaim bill of
hospitalization was submitted by the complainant for reimbursement to the Insurance company
under claim no. 100978301 on 22.04.2020, which was not settled by the Insurance Company after
complying the queries by him. The complainant represented his case to GRO on 10.11.2020 for
settlement of the claim. But the insurance company reiterated its decision and he could not get any
relief from the Insurance Company. Being aggrieved complainant approached this forum for
redressal of his grievance.
Insurer’s argument:- The Insurance Company in its SCN dated 13.01.2021 submitted that
documents were required to be submitted by the complainant for settlement of the claim, but the
pre numbered paid receipt had not been received from the complainant. Since the query document
did not receive in the stipulated time, the claim was closed on non-submission of query documents.
If the original pre-numbered paid receipt is submitted by the complainant, the case may be
reopened for settlement. Hence as per clause 5.6 of the policy the Respondent has closed the claim
in accordance with the terms and condition of the policy.
19) Reason for Registration of Complaint: Non settlement of mediclaim under health insurance
policy.
20) The following documents were placed for perusal.
a. Complaint letter
b. Copies of documents submitted by the complainant
c. Form VI A duly signed by the complainant.
d. SCN and a form VIIA duly signed by the Insurance Company
a. Result of hearing with both parties (Observations and Conclusion) :- :- I heard both
the sides, the complainant and the Insurance Company through GoToMeeting video conferencing
hearing on 21.1.2021. The complainant submitted that he had submitted all the documents raised in
the query letter by the insurance company, but the insurance company did not adhered to the
documents, being the duplicate copy. Again, he had submitted the bill showing the break up details
and numbered receipt duly certified by the Hospital. The Insurance Company submitted that pre-
numbered paid receipt of Rs. 12000 was required to be submitted by the complainant for settlement
of the claim, but the pre numbered paid receipt had not been received from the complainant. Since
the query document was not received in the stipulated time, the claim was closed on non-
submission of reply to the query documents. If the original pre-numbered paid receipt is submitted
by the complainant, the case may be reopened for settlement.
On perusal of the documents exhibited and oral submissions made during the hearing, I find that
copy of bill with reg. no. 20821 dated 03.03.2020 for Rs. 12000 and duplicate bill cum receipt
number 19-20/11629 dated 03.03.2020 mentioning the break up of Rs. 12000 ( Lens charge Rs.
5000 + Rs. 7000 for operation) and cash received are sufficient evidence to fulfill the query
documents. Since the original bills have been misplaced by the TPA and the complainant had
submitted the duplicate of these documents duly certified by the Hospital, the claim can be settled
on the basis of these documents.
Accordingly, an Award is passed with a direction to the Insurance Company to pay the claim
to the insured, as admissible.
22. The attention of the Complainant and the Insurer is hereby invited to the following provisions
of Insurance Ombudsman Rules, 2017:
h. According to Rule 17(5) of Insurance Ombudsman Rules, 2017, a copy of the award shall
be sent to the complainant and the insurer named in the complaint.
i. As per Rule 17(6) of Insurance Ombudsman Rules, 2017, the insurer shall comply with
the award within 30 days of the receipt of the award and intimate compliance of the
same to the Ombudsman.
Place: Jaipur SANDHYA BALIGA
Dated: 28.01.2021 INSURANCE OMBUDSMAN
PROCEEDINGS BEFORE
THE INSURANCE OMBUDSMAN, STATE OF RAJASTHAN
UNDER THE INSURANCE OMBUDSMAN RULES, 2017
OMBUDSMAN – MS. SANDHYA BALIGA
CASE OF SITA RAM SAINI V/S THE ORIENTAL INSURANCE CO.LTD
COMPLAINT REF: NO JPR-H-050-2021-0152
AWARD No. IO/JPR/H/A/1920/000
1.
Name & Address of the Complainant
Shri Sita Ram Saini, Axis Bank Ltd, Sugan
Singh Circle, Nagaur.
2.
Policy No:
Type of Policy
Commencement of the Risk
124500/48/2020/3941
Group Health Insurance (Axis Bank
employees)
AWARD
Taking into account the facts and circumstances of the case and the submissions
made by both the parties during the course of hearing, the Insurance Company is
directed to pay the claim to the insured, as admissible.
Sum Insured
01.10.2019 to 30.09.2020
3.
Name of the insured
Name of the policyholder
Smt. Bhagwati Devi, Mother
Shri Sita Ram Saini
4.
Name of the insurer
The Oriental Insurance Company Ltd
5.
Date of Repudiation
26.08.2020
6.
Reason for repudiation
Admission only for evaluation purpose,
repudiated as per clause no.4.10
7.
Date of receipt of the Complaint
02.12.2020
8.
Nature of complaint
Full Repudiation of mediclaim
9.
Amount of Claim
Rs. 46027/-
10.
Date of Partial Settlement
N.A.
11.
Amount of relief sought
Rs. 46027/-
12.
Complaint registered under
Rule no: of IOB rules
13(1) (b)
13.
Date of hearing/place
28.01.2021/ Video Conferencing through
GoToMeeting
14.
Representation at the hearing
m. For the Complainant
Shri Sita Ram Saini
n. For the insurer
Shri R. K.Banthia, Dy. Manager
15
Complaint how disposed
Award
16
Date of Award/Order
28.01.2021
17). Brief fact of the case : Mr. Sita Ram Saini (herein after referred to as the complainant)
had filed a complaint against the decision of The Oriental Insurance Company Ltd (herein
after referred to as respondent Insurance Company) alleging repudiation of mediclaim
under group Health Insurance policy no. 124500/48/2020/3941.
18) Cause of Complaint:
Complainant’s argument: The complainant stated that he had coverage of group health insurance
mediclaim policy taken by his employer from Respondent insurance company with risk
commencement date from 01.10.2019 to 30.09.2020 covering of his mother. The complainant’s
mother (insured) was admitted in Fortis Hospital, Jaipur with complaint of vertigo, chest pain,
sweating and unconsciousness on 09.08.2020. She was discharged on 11.08.2020 after treatment.
The Mediclaim for reimbursement of the treatment taken were submitted by the Complainant to the
Insurance Company vide claim no. 5049608943, which was repudiated by Insurance Company on
26.08.2020 on the ground that patient admitted exclusively for evaluation purpose. The claim was
not admissible as per clause no. 4.10 of the policy. The complainant approached GRO for
reconsidering the Mediclaim on 27.08.2020. But the Insurance Company reiterated its decision vide
letter dated 21.09.2020 and Complainant did not get any relief from the Insurance Company. Being
aggrieved complainant approached this forum for redressal of his grievance.
Insurer’s argument:- The Insurance Company in its SCN dated 18.12.2020 submitted that Patient
admitted for c/o Vertigo, Chest Pain, Ghabrahat, Sweating, synocope/LOC. During the
hospitalization, she underwent series of investigations. She was diagnosed as Syncope under
evaluation, lacunar infarcts, anemia with EF-normal. On scrutiny of claim documents, it is
observed that patient was admitted only for evaluation purpose and no active line of treatment was
done. Hence claim was repudiated as per clause no. 4.10 – “Expenses incurred at Hospital or
nursing home primarily for evaluation/diagnostic purposes which is not followed by the active
treatment for the ailment during the hospitalized period.” Therefore the Respondent had repudiated
the claim in accordance with the terms and condition of the policy.
19) Reason for Registration of Complaint: Total repudiation of mediclaim under health insurance
policy.
20) The following documents were placed for perusal.
Complaint letter
Copies of documents submitted by the complainant
Form VI A duly signed by the complainant.
SCN and a form VIIA duly signed by the Insurance Company
Result of hearing with both parties (Observations and Conclusion) :- I heard both the sides,
the Complainant and the Insurance Company through video conferencing on 28.01.2021. The
Complainant submitted that her mother was admitted in the said hospital with complaint of vertigo,
chest pain, syncope and in unconscious condition. The hospitalization was on the advice of the
treating doctor; hence the claims were wrongly rejected by the insurance company. The Insurance
Company stated that hospitalization under the claim was only for investigation and diagnostic
purpose, therefore the claim was repudiated under exclusion clause 4.10 of the policy.
On perusal of the documents exhibited and oral submissions during the course of Video
Conferencing, I find that the the patient was hospitalized on the advice by the treating doctor and
IV fluid and injections were administered for her treatment during hospitalization, which was
active line of treatment. Therefore in the said claim, treatment and hospitalization was at the behest
of doctor and I see no reason to question the list of treatment given by the Doctor.
Accordingly, an Award is passed with a direction to the Insurance Company to pay the claim
to the insured, as admissible.
22. The attention of the Complainant and the Insurer is hereby invited to the following provisions
of Insurance Ombudsman Rules, 2017:
j. According to Rule 17(5) of Insurance Ombudsman Rules, 2017, a copy of the award shall
be sent to the complainant and the insurer named in the complaint.
k. As per Rule 17(6) of Insurance Ombudsman Rules, 2017, the insurer shall comply with
the award within 30 days of the receipt of the award and intimate compliance of the
same to the Ombudsman.
Place: Jaipur SANDHYA BALIGA
Dated: 28.01.2021 INSURANCE OMBUDSMAN
AWARD
Taking into account the facts and circumstances of the case and the submissions
made by both the parties during the course of hearing, the Insurance Company is
directed to pay the claim to the insured, as admissible.
PROCEEDINGS BEFORE
THE INSURANCE OMBUDSMAN, STATE OF WESTERN U.P AND UTTARAKHAND
UNDER THE INSURANCE OMBUDSMAN RULES, 2017
OMBUDSMAN : SH. C.S. PRASAD
CASE OF SH. SAURABH MALHOTRA V/S. GODIGIT GENERAL INS. CO.
COMPLAINT REF. NO. : NOI- H- 059- 2021 - 0155
AWARD NO:
1.
Name & Address of the Complainant
Sh. Saurabh Malhotra
G.S. Sadan, Gopal Dhara,Dharanaula,
Almora,Uttrakhand-263601
Ph. No.07055001342
2.
Policy No:
Type of Policy
Duration of policy/Policy period
D021043678
Digit Illness Group Insurance Policy
24.07.2020 to 23.07.2021
3.
Name of the insured
Name of the policyholder
Sh. Saurabh Malhotra
Alpla India Private Limited
4.
Name of the insurer
Godigit General Ins. Co. Ltd.
5.
Date of Repudiation
22.10.2020
6.
Reason for repudiation
Claim repudiated on the ground of Hotel
quarantine is not payable.
7.
Date of receipt of the Complaint
04.11.2020
8.
Nature of complaint
Group Mediclaim
9.
Amount of Claim
--
10.
Date of Partial Settlement
NA
11.
Amount of relief sought
The Complainant did not submit Annex
VI A
12.
Complaint registered under
Rule no: of IOB rules, 2017
13 1 (b)
13.
Date of hearing/place
11.01.2021 / NOIDA
14.
Representation at the hearing
14. For the Complainant
Absent
15. For the insurer
Mr. Omkhare T, Health claims
15
Complaint how disposed
Award
16
Date of Award/Order
13.01.2021
vii. Brief Facts of the Case:- Sh. Saurabh Malhotra, the Complainant had taken Digit Illness Group
Insurance Policy No. D021043678 from Godigit General Ins. Co. Ltd. for the period from
24.07.2020 to 23.07.2021. The policy was issued to Alpla India Private Limited. His claim was
rejected by the Insurance Company on the ground of Hotel quarantine is not payable.
Aggrieved, he requested the Insurer including its GRO to reconsider the claim but failed to get
any relief. Thereafter, he has preferred a complaint to this office for resolution of his
grievance.
viii. Cause of Complaint:-
Complainant’s argument:- The complainant Sh. Saurabh Malhotra stated in his complaint that he
came covid-19 positive on 6
th
Sep 2020 in Haldwani (Uttarakhand), then he got calls from govt.
covid control team asking him to go for quarantine center that was made for non-serious
patients. As there was only one covid dedicated hospital at Haldwani called STH, and that too was
taking serious patients with limited beds. Private hospitals at Haldwani were not taking the covid
patients during that period. So, he opted for paid quarantine center Hotel Royal Windsor. After
discharge, he submitted the documents along with claim to the insurance company Go Digit
insurance. His claim was rejected by the Insurer on 22.10.2020.
Insurers’ argument:- The insurer stated in their SCN that the complainant is a beneficiary under
Group Insurance Policy and the Group Policy is issued to M/s. Alpla India Private Limited under the
name of Digit Illness Group Insurance Policy.
The Complainant was diagnosed with COVID virus on 6
th
September 2020 and was quarantined
and isolation in “Royal Windsor Hotel” Nainital Road, Ranibagh, Kathgodam from 8
th
September
2020 to 15
th
September 2020, pursuant to which, he has lodged a claim for reimbursement under
the policy.
The Insurance Company has thoroughly verified the documents submitted by the Complainant
and explained to him that same is not covered under the policy. Since, it is not specifically
covered. However, the Complainant is not convinced with their explanation, the company has
repudiated the claim of the Complainant vide letter dated 22
nd
October 2020.
It is submitted that, the term “Hospital” is specifically defined under the policy which is
reproduced hereunder;
Hospital means any institution established for in-patient care and day care treatment of illness
and/or injuries and which has been registered as a hospital with the local authorities under Clinical
Establishments (Registration and Regulation) Act 2010 or under enactments specified under the
Schedule of Section 56(1) and the said Act Or complies with all minimum criteria as under:
i) has qualified nursing staff under its employment round the clock;
ii) has at least 10 in-patient beds in towns having a population of less than 10,00,000
and at least 1 inpatient beds in all other places;
iii) has qualified medical practitioner(s) in charge round the clock;
iv) has a fully equipped operation theatre of its own where surgical procedures are
carried out;
v) maintains daily records of patients and makes these accessible to the insurance
company’s authorized personnel;
However, the complainant was kept in a “Hotel” and the said hotel does not fall under the
definition of Hospital. Since, it does not meet out the criteria mentioned in the policy terms and
conditions. It is further submitted that, the Insurance Regulatory and Authority of India has issued
a circular on 16
th
July 2020. Through which the Authority has extended the definition of Hospital
and given recognition to “Make shift or temporary hospital” permitted by the Government for
settlement of health insurance claims. It is pertinent to mention here that, the hotel in question
does not fall even under the extended definition, since it is not under the supervision of Medical
Practitioner or any hospital. As per provided document temperature was monitored at hotel and
does not specify the details of Physician or Hospital, and hence not considered as hospitalization.
It is submitted that, on perusal of the Discharge summary issued by the Hotel it is evident that, it
does not fall under the definition of hospital under the policy nor under the extended definition of
Hospital under the circular. It is also further submitted that the discharge summary issued by
Hospital is not certified by official seal under the medical practitioner. As such, the claim made by
the complainant does not fall under the purview of policy terms and conditions.
It is submitted that, at this juncture, the company would also like to draw the attention of Hon’ble
ombudsman to section 2 (a) at page no. 13 of the terms and conditions which read as under;
SECTION 2. VIRUS DETECTION & QUARANTINE ALLOWANCE
w. We will not pay for any self-Quarantine in any facility other than Government
Authorized Hospital.
x. Home hospitalisation (Domiciliary hospitalisation) expenses are not covered
The Company has repudiated the claim as per policy terms and conditions.
19) Reason for Registration of Complaint: - Repudiation of Mediclaim
20) The following documents were placed for perusal:-
a) Complaint letter
b) Policy copy
c) Form VI A duly signed by the complainant.
d) SCN of the case.
21) Observations and Conclusion :-
The Insurance Company appeared for personal hearing through video call and reiterated their
submissions. The Complainant Sh. Saurabh Malhotra was absent at the time of hearing. The
case was decided on merit basis.
The Insurance Company does not dispute that the Complainant was diagnosed with COVID
virus on 6
th
September 2020 and was quarantined and kept in isolation in “Royal Windsor
Hotel” Nainital Road, Ranibagh, Kathgodam from 8
th
September 2020 to 15
th
September
2020. The claim has been denied on the grounds that the hotel is not a hospital and there is
no evidence that the insured received any medical attention or was under the supervision of
a doctor.
Ongoing through the documents exhibited by both the parties and the oral submission made
by the Insurer, it is observed that the Insurance Company accepts that the complainant was
Covid Positive. As there was only one covid dedicated hospital at Haldwani called STH, and
that too was taking serious patients with limited beds. Private hospitals at Haldwani were not
taking the covid patients during that period. The complainant did not want to go home to
infect others; therefore, he chose to stay in a paid quarantine center Hotel Royal Windsor. As
per available documents with the Ombudsman office, Hotel Royal Windsor, Kathgodam was
dedicated quarantine center by the District Magistrate’s order dated 30.05.2020. Therefore,
it is an authorized quarantine Center. Hence, the Insurance Company is directed to pay the
admissible claim to the complainant.
AWARD
Taking into account the facts and circumstances of the case and the submissions made
by both the parties during the course of hearing, the Insurance Company is directed to
pay the admissible claim to the complainant.
The complaint is treated as disposed off accordingly.
22. The attention of the Complainant and the Insurer is hereby invited to the following
provisions of Insurance Ombudsman Rules, 2017:
a) According to Rule 17(6) of Insurance Ombudsman Rules,2017, the insurer shall comply with the
award within thirty days of the receipt of the award and intimate compliance of the same to the
Ombudsman.
Place: Noida. C.S. PRASAD
Dated: 13.01.2021 INSURANCE OMBUDSMAN
(WESTERN U.P. & UTTARAKHAND)
PROCEEDINGS BEFORE
THE INSURANCE OMBUDSMAN, STATE OF WESTERN U.P. & UTTARAKHAND
UNDER INSURANCE OMBUDSMAN RULES, 2017
OMBUDSMAN – SH. C.S. PRASAD
CASE OF SH. VISHNU KUMAR GUPTA V/S UNITED INDIA INSURANCE COMPANY LTD.
COMPLAIN REF. NO.: NOI-H-051-2021-0133
AWARD NO:
1.
Name & Address of the Complainant
Sh. Vishnu Kumar Gupta,
H.No. III, K-35, Nehru Nagar,
Rakesh Marg, Ghaziabad,
Uttar Pradesh-201001.
Ph. No.09654537678
2.
Policy No:
Type of Policy
Duration of policy/Policy period
5001002819P113004444
Tailormade Group Mediclaim Policy
(Retirees)
Indian Banks’ Association
(A/c. Kotak Mahindra Bank Ltd.)
01.11.2019 to 31.10.2020
3.
Name of the Insured
Name of the policyholder
Sh. Vishnu Kumar Gupta
Sh. Vishnu Kumar Gupta
4.
Name of the insurer
United India Insurance Company Limited
5.
Date of Repudiation
03.08.2020
6.
Reason for repudiation
Day Care treatment does not fall under
Day Care Procedure, hence, not payable.
7.
Date of receipt of the Complaint
12.10.2020
8.
Nature of complaint
Group Mediclaim
9.
Amount of Claim
--
10.
Date of Partial Settlement
--
11.
Amount of relief sought
Rs.15,790/- as per Annex VI A
12.
Complaint registered under
IOB rules, 2017
13 (1)(b)
13.
Date of hearing/place
11.01.2021 / NOIDA
14.
Representation at the hearing
o. For the Complainant
Sh. Vishnu Kumar Gupta
p. For the insurer
Ms. Pamela Pinto, Dy. Manager
15
Complaint how disposed
Award
16
Date of Award/Order
14.01.2021
17. Brief Facts of the Case:- Sh. Vishnu Kumar Gupta, the Complainant had taken Tailormade
Group Mediclaim Policy (Retirees) No.5001002819P113004444 for the period from 01.11.2019
to 31.10.2020. The Group Mediclaim Policy was issued to Kotak Mahindra Bank Ltd. covering
their Retired Employees. The reimbursement of bills was rejected by the Insurance Company
on the ground that the Day Care treatment does not fall under Day Care
Procedure/Treatments. Aggrieved, he requested the Insurer including its GRO to reconsider
the claim but failed to get any relief. Thereafter, he has preferred a complaint to this office for
resolution of his grievance.
18. Cause of Complaint:-
Complainant’s argument:- Sh. Vishnu Kumar Gupta, the Complainant stated that on
25.06.2020, suddenly a Haemorrage Stroke occurred in his left eye. He was hospitalized at Eye
Trust Clinic and Day Care Centre, Ghaziabad for the ongoing treatment of the said disease. On
18.07.2020, the doctor further checked his affected eye and advised him for Intraviteral
Injection for proper and speedy recovery. Accordingly, the same treatment was given to him
on 19.07.2020 by the doctor in its daycare clinic and he raised the claim bill for Rs.15,790/- for
reimbursement which was rejected by the Insurer with the reason “Daycare Treatment does
not fall under daycare procedure/treatments, hence, the claim is rejected”.
Insurers’ argument:- The Insurance Company stated in the SCN that Sh. Vishnu Kumar Gupta
aged 62 years admitted to Eye Trust Clinic & Day Care Centre-Ghaziabad, diagnosed as Left
Eye Macular Edema and got administered Intraviteral Injection Razumab on 19.07.2020,
received a reimbursement claim of Rs.15,790/-.
On scrutiny, it is found that admission was only for administering Intravitreal Injection. As per
the said GMC Policy, the above said procedure was done under day care which is not listed in
the policy clause 3.3 – Day Care List.
As per the policy terms and conditions, the treatment of Eye Surgery is payable but
hospitalization solely for the administration of intravitreal injection is not payable.
In view of the above, this claim was recommended for denial “Treatment does not fall under
Day Care Procedures/Treatments”.
19) Reason for Registration of Complaint: - Rejection of Mediclaim
20) The following documents were placed for perusal.
a)Customer complaint
b) Annexure vi and vi (a)
c) Policy Copy
d) SCN
21) Observations &Conclusion :-
Both the parties appeared for personal hearing through video call and reiterated their
submissions. The complainant reiterated that a Haemorrage Stroke occurred in his left eye,
but his claim for intravitreal injection has been rejected by the insurance company.
The Insurance Company reiterated that per the policy terms and conditions, the treatment of
Eye Surgery is payable but hospitalization solely for the administration of intravitreal injection
is not payable.
Ongoing through the documents exhibited and the oral submissions made by both the parties,
it is observed that the cause of complaint has arisen because the Insurer has considered
administration of intra-vitrealinjections as OPD procedures. In the judgment dated
27.09.2016, in case of the General Manager, United India vs. Shri Shaukat Ali Khan, State
Consumer Dispute Redressal Commission, West Bengal, while dealing the similar case of
(ARMD) and administration of Injection, has held that administration of intra-vitrealinjection is
a surgical procedure and not an OPD procedure,lthough it has reduced hospitalization and
additional cost of post operation care which were associated with other form of treatment.
Similarly, in the case of Sh. Jai Karmakar Vs. United India Insurance Co. Ltd.: State Consumer
Disputes Redressal Commission in its judgment dated 16.08.2016, has held that the CNVM or
intra-vitreal injection is a surgical procedure which should be carried out under an aseptic
condition and should be performed in operation room. Further, policy conditions maintain
that the time limit of 24 hours is not applied in case of eye surgery.
From the above discussion, it is absolutely clear that the administration of intra-vitreal
injection is to be treated as surgical procedure. Respondent Company has wrongly repudiated
the claim.
Repudiation is set aside and respondent company is advised to settle the claim by treating
administration of injection as surgical procedure and not as OPD treatment.
AWARD
Taking into account the facts and the submissions made by both the parties during
the course of hearing, repudiation is set aside and respondent company is advised to
settle the claim by treating administration of injection as surgical procedure and not
as OPD treatment.
The complaint is disposed off accordingly.
22. The attention of the Complainant and the Insurer is hereby invited to the following
provisions of Insurance Ombudsman Rules, 2017:
a) According to Rule 17(6) of Insurance Ombudsman Rules, 2017, the insurer shall comply with the
award within thirty days of the receipt of the award and intimate compliance of the same to the
Ombudsman.
Place: Noida. C.S. PRASAD
Dated: 14.01.2021 INSURANCE OMBUDSMAN
(WESTERN U.P. & UTTARAKHAND)
PROCEEDINGS BEFORE
THE INSURANCE OMBUDSMAN, STATE OF WESTERN U.P. & UTTARAKHAND
UNDER INSURANCE OMBUDSMAN RULES, 2017
OMBUDSMAN – SH. C.S. PRASAD
CASE OF SH. PUSHKAR SINGH BADWAL V/S UNITED INDIA INSURANCE COMPANY LTD.
COMPLAIN REF. NO.: NOI-H-051-2021-0118
AWARD NO:
1.
Name & Address of the Complainant
Sh. Pushkar Singh Badwal
C/O S/O Jaman Singh Badwal
AH 102, 1
st
Floor, Raj Empire,
Rajnagar Extension, Morti,
Ghaziabad,Uttar Pradesh-201003.
Ph. No.09818658294
2.
Policy No:
Type of Policy
Duration of policy/Policy period
5001002818P111088681
Group Health Insurance Policy
Indian Banks’ Association (OBC)
01.10.2019 to 30.09.2020
3.
Name of the Insured
Name of the policyholder
Sh. Pushkar Singh Badwal
Sh. Pushkar Singh Badwal
4.
Name of the insurer
United India Insurance Company Limited
5.
Date of Repudiation
30.03.2020
6.
Reason for repudiation
Admission for administration of
Intravitral Injection is not covered as per
Clause 3.4.
7.
Date of receipt of the Complaint
30.09.2020
8.
Nature of complaint
Group Mediclaim
9.
Amount of Claim
--
10.
Date of Partial Settlement
--
11.
Amount of relief sought
Rs.43,852/- as per Annex VI A
12.
Complaint registered under
IOB rules, 2017
13 (1)(b)
13.
Date of hearing/place
11.01.2021 / NOIDA
14.
Representation at the hearing
l) For the Complainant
Sh. Pushkar Singh Badwal
m) For the insurer
Ms. Pamela Pinto, Dy. Manager
15
Complaint how disposed
Award
16
Date of Award/Order
14.01.2021
17) Brief Facts of the Case:- Sh. Pushkar Singh Badwal, the Complainant had taken Group Health
Insurance Policy No. 5001002818P111088681 for the period from 01.10.2019 to 30.09.2020. The
Group Mediclaim Policy was issued to Oriental Bank of Commerce covering their Employees with
dependent members. The reimbursement of bills was rejected by the Insurance Company on the
ground that the patient is claiming for Intravitreal Injections, which is not covered. Aggrieved, he
requested the Insurer including its GRO to reconsider the claim but failed to get any relief.
Thereafter, he has preferred a complaint to this office for resolution of his grievance.
18. Cause of Complaint:-
Complainant’s argument:- Sh. Pushkar Singh Badwal, the Complainant stated that his claim
regarding Accentrix injection (Intravitreal injection) which is used for treatment of Diabetic
Retinopathy was not settled by the Insurer Since January 2020. However, a similar claim having
the same injection i.e. Accentrix (for Diabetic Retinopathy) was passed in the month of March.
Insurers’ argument:- The Insurance Company stated in the SCN that they have received
reimbursement claim pertains to treatment being taken at Centre for Sight, New Delhi for
diagnosis – Focal Chorioretinal Inflammation and Intravitreal Injection being administered. The
Intravitreal Injection administration, it is an OPD treatment though this injection is given in the
operation theatre in view the nature of treatment it falls outside the scope of our health policies.
As per the policy terms and conditions, the treatment of Eye Surgery is payable but hospitalization
solely for the administration of intravitreal injection is not payable.
Administration of Inj. Avastin is a procedure for which hospitalization is not required and also not
enlisted in the day care procedure list of the policy. The procedure is payable only if it forms a
part of inpatient treatment in case of hospitalization or part of discharge advice upto the limits for
post hospitalization. Not payable if hospitalization is done only for administration of injection.
Hence the claim was repudiated on 30.03.2020.
19) Reason for Registration of Complaint: - Rejection of Mediclaim
20) The following documents were placed for perusal.
a)Customer complaint
b) Annexure vi and vi (a)
c) Reply of Insurance Company
d) SCN
o Observations & Conclusion :-Both the parties appeared for personal hearing through video
call and reiterated their submissions. The complainant reiterated that his claim regarding
Accentrix injection (Intravitreal injection) which is used for treatment of Diabetic Retinopathy
was not settled by the Insurer since January 2020. However, a similar claim having the same
injection i.e. Accentrix (for Diabetic Retinopathy) was passed in the month of March.
The Insurance Company reiterated that they have received reimbursement claim for
diagnosis – Focal Chorioretinal Inflammation and Intravitreal Injection being administered.
The administration of Intravitreal Injection is an OPD treatment though this injection is given
in the operation theatre. The nature of treatment falls outside the scope of the health
policies. As per the policy terms and conditions, the treatment of Eye Surgery is payable but
hospitalization solely for the administration of intravitreal injection is not payable.
Administration of Inj. Avastin is a procedure for which hospitalization is not required and so
not enlisted in the day care procedure list of the policy. The procedure is payable only if it
forms a part of inpatient treatment in case of hospitalization or part of discharge advice upto
the limits for post hospitalization. Not payable if hospitalization is done only for
administration of injection. Hence the claim was repudiated on 30.03.2020.
Ongoing through the documents exhibited and the oral submissions made by both the
parties, it is observed that the cause of complaint has arisen because the Insurer has
considered administration of intra-vitrealinjections as OPD procedures. In the judgment
dated 27.09.2016, in case of the General Manager, United India vs. Shri Shaukat Ali Khan,
State Consumer Dispute Redressal Commission, West Bengal, while dealing the similar case
of (ARMD) and administration of Injection, has held that administration of intra-
vitrealinjection is a surgical procedure and not an OPD procedure, though it has reduced
hospitalization and additional cost of post operation care which were associated with other
form of treatment.
Similarly, in the case of Sh. Jai Karmakar Vs. United India Insurance Co. Ltd.: State Consumer
Disputes Redressal Commission in its judgment dated 16.08.2016, has held that the CNVM or
intra-vitreal injection is a surgical procedure which should be carried out under an aseptic
condition and should be performed in operation room. Further, policy conditions maintain
that the time limit of 24 hours is not applied in case of eye surgery.
From the above discussion, it is absolutely clear that the administration of intra-vitreal
injection is to be treated as surgical procedure. Respondent Company has wrongly
repudiated the claim.
Repudiation is set aside and respondent company is advised to settle the claim by treating
administration of injection as surgical procedure and not as OPD treatment.
AWARD
Taking into account the facts and the submissions made by both the parties during the
course of hearing, repudiation is set aside and respondent company is advised to settle
the claim by treating administration of injection as surgical procedure and not as OPD
treatment.
The complaint is disposed off accordingly.
22. The attention of the Complainant and the Insurer is hereby invited to the following
provisions of Insurance Ombudsman Rules, 2017:
a) According to Rule 17(6) of Insurance Ombudsman Rules, 2017, the insurer shall comply with the
award within thirty days of the receipt of the award and intimate compliance of the same to the
Ombudsman.
Place: Noida. C.S. PRASAD
Dated: 14.01.2021 INSURANCE OMBUDSMAN
(WESTERN U.P. & UTTARAKHAND)
PROCEEDINGS BEFORE
THE INSURANCE OMBUDSMAN, STATE OF WESTERN U.P. & UTTARAKHAND
UNDER INSURANCE OMBUDSMAN RULES, 2017
OMBUDSMAN – SH. C.S. PRASAD
CASE OF SH. SHYAM SUNDER ARORA V/S UNITED INDIA INSURANCE COMPANY LTD.
COMPLAIN REF. NO.: NOI-H-051-2021-0153
AWARD NO:
1.
Name & Address of the Complainant
Sh. Shyam Sunder Arora
19 – Raja Road,
Laxmi Park, Dehradun,
Uttarakhand-248001
Ph. No.09412989606
2.
Policy No:
Type of Policy
Duration of policy/Policy period
Sum Insured
5001002819P112329452
Tailormade Group Mediclaim Policy
(Retirees)
Indian Banks’ Association (Canara Bank)
01.11.2019 to 31.10.2020
Rs.4,00,000/-
3.
Name of the Insured
Name of the policyholder
Sh. Shyam Sunder Arora
Sh. Shyam Sunder Arora
4.
Name of the insurer
United India Insurance Company Limited
5.
Date of Repudiation
30.03.2020 and 05.10.2020
6.
Reason for repudiation
Admission for administration of
Intravitral Injection is not covered as per
Clause 3.4.
7.
Date of receipt of the Complaint
05.10.2020
8.
Nature of complaint
Group Mediclaim
9.
Amount of Claim
--
10.
Date of Partial Settlement
--
11.
Amount of relief sought
Rs.84,493/- against two claims as per
Annex VI A
12.
Complaint registered under
IOB rules, 2017
13 (1)(b)
13.
Date of hearing/place
25.01.2021 / NOIDA
14.
Representation at the hearing
a. For the Complainant
Sh. Shyam Sunder Arora
b. For the insurer
Ms. Pamela Pinto, Dy. Manager
15
Complaint how disposed
Award
16
Date of Award/Order
28.01.2021
17. Brief Facts of the Case:- Sh. Shyam Sunder Arora, the Complainant had taken Group Health
Insurance Policy No. 5001002819P112329452 for the period from 01.11.2019 to 31.10.2020.
The Group Mediclaim Policy was issued to Canara Bank covering their Retired Employees
Without Domiciliary with dependent members. The reimbursements of bills were rejected by
the Insurance Company on the ground that the patient is claiming for Intravitreal Injections,
which is not covered. Aggrieved, he requested the Insurer including its GRO to reconsider the
claim but failed to get any relief. Thereafter, he has preferred a complaint to this office for
resolution of his grievance.
18. Cause of Complaint:-
(ii) Complainant’s argument:- Sh. Shyam Sunder Arora, the Complainant stated that he submitted
two following claims to Good Health Insurance TPA Ltd :
● Claim No.900221 for Rs.42,755/- claim on 16.06.2020
● Claim No.908745 for Rs.41,378/- claim on 14.07.2020
Both these claims pertain to the treatment – Surgery: Intra-vitreal injection in eye which is an
eye surgery. But the Insurance Company rejected his claims.
(iii) Insurers’ argument:- The Insurance Company stated in the SCN that they have received
reimbursement claim No.900221 of the complainant. The complainant diagnosis Macular
Edema and had taken the treatment in Singh Eye Hospital/Dev Bhumi Eye Clinic, Dehradun on
21.03.2020 for the claimed amount of Rs.42,755/- which was repudiated under Exclusion
Clause 3.3 as the hospitalization period was less than 24 hours and patient was given
Intravitreal Injection Ozurdex which does not come under the list of procedures under the Day
Care List. Again they received second reimbursement claim No.908745 of the complainant for
the same treatment for Macular Edema and had taken the treatment in The Eye Clinic,
Dehradun on 26.06.2020 for the claimed amount of Rs.41,378/- which was also repudiated
under Exclusion Clause 3.3 as the hospitalization perod was less than 24 hours and patient was
given Intravitreal Injection Ozurdex which does not come under the list of procedures under
the Day Care List. As per their Health Department, Head Office’s instructions, the Intravitreal
Injections claim are not payable as per the terms and conditions of the Policy.
19) Reason for Registration of Complaint: - Rejection of Mediclaim
20) The following documents were placed for perusal.
a) Customer complaint
b) Annexure vi and vi (a)
c) Reply of Insurance Company
d) SCN
f) Observations & Conclusion :-
Both the parties appeared for personal hearing through video call and reiterated their
submissions. The complainant reiterated that his two claims regarding Ozurdex injection
(Intravitreal injection) which are used for treatment of Macular Edema were rejected by the
Insurer.
The Insurance Company reiterated that they have received two reimbursement claims for
diagnosis – Macular Edema and Intravitreal Injections being administered. The Intravitreal
Injection administration is an OPD treatment though this injection is given in the operation
theatre. As per the policy terms and conditions, the treatment of Eye Surgery is payable but
hospitalization solely for the administration of intravitreal injection is not payable.
Administration of Inj. Ozurdex is a procedure for which hospitalization is not required and
also not enlisted in the day care procedure list of the policy. The procedure is payable only if
it forms a part of inpatient treatment in case of hospitalization or part of discharge advice
upto the limits for post hospitalization. Not payable if hospitalization is done only for
administration of injection. Hence, the claims were repudiated.
Ongoing through the documents exhibited and the oral submissions made by both the
parties, it is observed that it is obvious that the cause of complaint has arisen because the
Insurer has considered administration of intra-vitreal injections as OPD procedures. In the
judgment dated 27.09.2016, in case of the General Manager, United India vs. Shri Shaukat Ali
Khan, State Consumer Dispute Redressal Commission, West Bengal, while dealing the similar
case of (ARMD) and administration of Injection, has held that administration of intra-vitreal
injection is a surgical procedure and not an OPD procedure, although it has reduced
hospitalization and additional cost of post operation care which were associated with other
form of treatment.
Similarly, in the case of Sh. Jai Karmakar Vs. United India Insurance Co. Ltd.: State Consumer
Disputes Redressal Commission in its judgment dated 16.08.2016, has held that the CNVM or
intra-vitreal injection is a surgical procedure which should be carried out under an aseptic
condition and should be performed in operation room. Further, policy conditions maintain
that the time limit of 24 hours is not applied in case of eye surgery.
From the above discussion, it is absolutely clear that the administration of intra-vitreal
injection is to be treated as surgical procedure. Respondent Company has wrongly
repudiated the claims.
Repudiation is set aside and respondent company is advised to settle both the claims by
treating administration of injection as surgical procedure and not as OPD treatment.
AWARD
Taking into account the facts and the submissions made by both the parties during
the course of hearing, repudiations are set aside and respondent company is advised
to settle both the claims by treating administration of injection as surgical procedure
and not as OPD treatment.
The complaint is disposed off accordingly.
22. The attention of the Complainant and the Insurer is hereby invited to the following
provisions of Insurance Ombudsman Rules, 2017:
a) According to Rule 17(6) of Insurance Ombudsman Rules, 2017, the insurer shall comply with the
award within thirty days of the receipt of the award and intimate compliance of the same to the
Ombudsman.
Place: Noida. C.S. PRASAD
Dated: 28.01.2021 INSURANCE OMBUDSMAN
(WESTERN U.P. & UTTARAKHAND)
AWARD NO.IO/KOC/A/HI/0347/2020-2021
PROCEEDINGS OF
THE INSURANCE OMBUDSMAN, KOCHI
(UNDER RULE NO. 13 1(b) READ WITH RULE 14 OF
THE INSURANCE OMBUDSMAN RULES, 2017)
Complaint No. KOC-H-051-2021-0489
PRESENT: Ms. POONAM BODRA
INSURANCE OMBUDSMAN, KOCHI.
AWARD PASSED ON 18.01.2021
1.
Name and Address of the
complainant
:
Mr. Joseph V S,
33/2733 B, Pulluparambu Road,
Thammanam P O, Ernakulam-
682032
2.
Policy Number
:
5001002819P112203988
3.
Name of the Insured
:
Ms. Sheela Joseph
4.
Name of the Insurer
:
The United India Insurance Co.
Ltd.
5.
Date of receipt of Complaint
:
14.09.2020
6.
Nature of complaint
:
Rejection of mediclaim
7.
Amount of relief sought
:
--
8.
Date of hearing
:
18.12.2020
9.
Parties present at the
hearing
y. For the Complainant
:
Mr. Joseph V S (online)
z. For the Insurer
:
Ms. Srijani (online)
AWARD
This is a complaint filed under Rule 13 1(b) read along with Rule 14 of the Insurance Ombudsman Rules,
2017. The complaint is regarding rejection of mediclaim. . The complainant, Mr. Joseph V S is husband of
the policyholder.
1. Averments in the complaint are as follows:
The Complainant submitted that he was holding a health insurance policy with respondent insurer vide
policy No.5001002819P112203988. His wife is under treatment for cancer( multiple myeloma) since March
2017 with chemotherapy cybordex followed by Bortezomib and Zoledronic acid injection. The treatment
completed in November 2018. The case was followed up every 2 months and in September 2019. It is
noticed that cancer is relapsed and - ie Chemotherapy with C.pomalidomide (NATCO) 2mg capsule for 21
days with TDexamethasone 20mg, Zoledronic acid injection on day care basis. Due to the technological
advancement Doctor changed the drug which will give better result. The chemotherapy administered is not
adjuvant chemotherapy. Before the lapse of cancer, the chemotherapy drug the chemotherapy was taken
once in 14 days and now the chemotherapy drug (capsule) is taken for 21 days and Zoledronic injection
once in two months and T.dexamethasone once in a week. The bill was rejected citing that the claim is not
admissible as it does not fall within the scope of the policy. However the previous treatment for the above
disease on the same lines has been awarded by this forum vide Award No.IO/KOC/A/HI/0015/2020-2021.
Relief sought is Rs.80959/- plus interest at 24% and damages Rs.10,000/-.
2. The Respondent Insurer entered appearance and filed a self contained note. It is submitted that
We have issued a group Mediclaim policy to Indian Bank retirees without domiciliary benefit
vide policy No: 5001002819P112203988 for period 01-Nov-2019 To 31-Oct-2020. Joseph V S
along with his spouse Sheela Joseph is included by Indian Bank in the list of insured persons.
Sheela Joseph was the patient in the claims regarding which the complaint has been made.
The complaint arose due to repudiation of the claims. She was diagnosed as a case of relapse multiple
myloma. She was admitted for administration of Inj.Zoledronic acid. On scrutiny of the claim documents by
TPA it was found that the hospitalization claims were for administration of Inj. Zoledronic acid on regular
basis in day care treatment. Drug view :Zoledronic acid is a supportive care drug in the category of
bisphosphonates. . Zoledronic acid is used as a support medication to treat symptoms of cancer such as
hypercalcemia (high blood calcium levels) or to decrease complications (such as fractures or pain)
produced by bone metastasis (spread of cancer to the bone). . Cancer cells that spread to the bone can
secrete substances that can cause cells found in the bone called osteoclasts to dissolve or "eat away" a
portion of the bone. These tumors or lesions weaken the bone and can lead to complications. Some of the
complications resulting from this bone breakdown are bone pain, fractures and less commonly,
hypercalcemia (increased levels of calcium in the blood). Zoledronic acid is a bisphosphonate.
Bisphosphonate medications are used to slow down the osteoclast's effects on the bone. In doing this it
can be useful in slowing down or preventing the complications (bone pain, fractures, or high calcium levels)
of the bone breakdown.. Claimant has submitted reimbursement claims for treatment taken of
injection Zoledronic acid , which falls under the entity, Targeted therapy & Adjuvant therapy. Such claims
are not admissible when the drugs are being administered on a stand-alone basis. Also, it is pertinent to
note that the entity of day care treatments present in the policy terms & conditions clause 3.4 highlights
the term, "Parenteral Chemotherapy". Hence, in toto, the claims lodged by the Insured members for
claiming the Hospitalization expenses incurred towards administration of INJ. Zoledronic acid on a "per se"
basis are not admissible since the period of hospitalization involved in such cases is less than 24 hours &
the said entity is also not listed under the list of "Day care treatments" present in the policy. . Hence such
claims are not admissible as per policy clause 2.19 and 3.4 of the policy.
These are not payable standalone and also not covered on day care list. Moreover, claim
number 20201013B005RH02798 is the post hospitalization claim of claim number
20200811B005RH01465 . Since claim number 20200811B005RH01465 is not payable thus claim number
20201013B005RH02798 was also repudiated. Accordingly the claims were repudiated. The claim has
been processed as per policy terms and conditions.
Clause 2.10 of the policy reads as under :
DAY CARE TREATMENT: Day care Treatment refers to medical treatment and or surgical procedure which is
: i. undertaken under general or local anesthesia in a hospital/day care Centre in less than a day because of
technological advancement, and ii. Which would have otherwise required a hospitalization of more than a
day. Treatment normally taken on an outpatient basis is not included in the scope of this definition
As per clause 3.3 of policy : Expenses on Hospitalization for minimum period of a day are admissible.
However, this time limit is not applied to treatments such as:
1
Adenoidectomy
20
Haemo dialysis
2
Appendectomy
21
Fissurectomy /
Fistulectomy
3
Ascitic / Plueral tapping
22
Mastoidectomy
4
Auroplasty not Cosmetic
in nature
23
Hydrocele Surgeries
5
Coronary/ Renal
Angiography
24
Hysterectomy
6
Coronary angioplasty
25
Inguinal/ ventral/
umbilical/ femoral
hernia surgeries
7
Dental surgery
26
Parenteral
chemotherapy
8
D&C
27
Polypectomy
9
Excision of cyst/
granuloma/lump/tumor
28
Septoplasty
10
Eye surgery
29
Piles/ fistula surgeries
11
Fracture including hairline
fracture /dislocation
30
Prostate surgeries
12
Radiotherapy
31
Sinusitis surgeries
13
Chemotherapy including
parental chemotherapy
32
Tonsillectomy
14
Lithotripsy
33
Liver aspiration
15
Incision and drainage of
abscess
34
Sclerotherapy
16
Varicocelectomy
35
Varicose Vein
Ligation
17
Wound suturing
36
All scopies along
with biopsies
18
FESS
37
Lumbar puncture
19
Operations/Micro surgical operations on the
nose, middle ear/internal ear, tongue,
mouth, face, tonsils & adenoids, salivary
glands & salivary ducts, breast, skin &
subcutaneous tissues, digestive tract,
female/male sexual organs.
This condition will also not apply in case of stay in hospital of less than a day provided –
A) The treatment is undertaken under General or Local Anesthesia in a hospital / day care Centre in less
than a day because of technological advancement and B) Which would have otherwise required
hospitalization of more than a day.
As per clause 1.2.2 of policy : Pre-Hospitalisation and Post-Hospitalisation Expenses - Medical Expenses
relevant to the same condition for which the hospitalization is required incurred during the period up to 30
days prior to hospitalisation and during the period up to 90 days after the discharge from the
hospital. These expenses are admissible only if the primary hospitalisation claim is admissible under the
policy.
3. I heard the Complainant and the Respondent Insurer. The Complainant submitted that his wife is under
treatment for cancer( multiple myeloma) since March 2017 with chemotherapy cybordex followed by
Bortezomib and Zoledronic acid injection. The doctor advised to continue chemotherapy for 4 cycles with a
variant chemotherapy drug which will get better result. chemotherapy administered is not adjuvant
chemotherapy. The claim was rejected stating that the claim is not admissible. However the previous
treatment for the above disease on the same lines has been awarded by this forum. The Respondent
Insurer submitted that the claims lodged by the complainant for claiming the Hospitalization expenses
incurred towards administration of Inj. Zoledronic acid on a "per se" basis are not admissible since the
period of hospitalization involved in such cases is less than 24 hours & the said entity is also not listed
under the list of "Day care treatments" present in the policy. . Hence such claims are not admissible as per
policy clause 2.19 and 3.4 of the policy.
4. On scrutinizing the case it is found that the denial of such claim needs to be sympathetically considered.
Zoledronic acid, which is a bisphosphonate, is useful in slowing down or preventing the complications
(bone pain, fractures, or high calcium levels) of the bone breakdown. Claimant has submitted
reimbursement claims for treatment taken of injection Zoledronic acid , which falls under the entity,
Targeted therapy & Adjuvant therapy as explained by the respondent insurer. With the introduction of the
advanced medicines, the patients benefit a lot physically and mentally. Even though the treatment do not
come under day care treatment, the same is equal to chemotherapy including parental chemotherapy
which is payable under daycare treatment. This forum is of the opinion that the benefit of advancement of
the medical technology is to be considered and the patients who are otherwise also mentally worried need
not be harassed more. The respondent insurer was directed to give the admissible amount under the claim
and it is submitted that an amount of Rs./-1293 is deducted towards registration fee, Band-aid, Gause etc
and an amount of Rs.87092/- is admissible.
In the result, an award is passed, directing the Respondent Insurer to pay an amount of Rs.87092/- , within
the period mentioned hereunder. No cost.
As prescribed in Rule 17(6) of Insurance Ombudsman Rules, 2017, the Insurer shall comply with the award
within 30 days of receipt of the award and intimate compliance of the same to the Ombudsman.
Dated this the 18
th
day of January 2021.
Sd/-
(POONAM BODRA)
INSURANCE OMBUDSMAN
AWARD NO.IO/KOC/A/HI/0350/2020-2021
PROCEEDINGS OF
THE INSURANCE OMBUDSMAN, KOCHI
(UNDER RULE NO. 13 1(i) READ WITH RULE 14 OF
THE INSURANCE OMBUDSMAN RULES, 2017)
Complaint No. KOC-H-018-2021-0491
PRESENT: Ms. POONAM BODRA
INSURANCE OMBUDSMAN, KOCHI.
AWARD PASSED ON 18.01.2021
1.
Name and Address of the complainant
:
Mr. Ramakrishnan V
13/105B, Ambalaparambil (H),
Sankarapuram, Mulakunnathukavu
P.O, Thrissur 680581
2.
Policy Number
:
1851365
3.
Name of the Insured
:
Mr. Ramakrishnan V
4.
Name of the Insurer
:
HDFC ERGO General Insurance
Company Ltd.
5.
Date of receipt of Complaint
:
05.11.2020
6.
Nature of complaint
:
Refusal of renewal of health policy
7.
Amount of relief sought
:
--
8.
Date of hearing
:
11.12.2020
9.
Parties present at the hearing
n) For the Complainant
:
Mr. Ramakrishnan V (online)
o) For the Insurer
:
Mr. Sachin Kumar Verma (online)
AWARD
This is a complaint filed under Rule 13 1(b) read along with Rule 14 of the Insurance Ombudsman Rules,
2017. The complaint is regarding refusal of renewal of health policy. The complainant, Mr. Ramakrishnan
V is the policyholder.
1. Averments in the complaint are as follows:
The Complainant stated that his policy was not renewed stating past history of myocardial Infarction,
although renewal notices by email were being received. He had taken treatment for chest pain during the
policy and it is not a pre existing one. His policy was from 15/11/2019 and his treatment was only on
4/1/2020. In the policy there is a locking period of 24 months and the policy states that they will not pay
for more than one claim in a policy year. A notice mentioned that , “ There will be no changes in your policy
terms and conditions as detailed in your policy document. On renewal all continuity benefits shall be
available as per existing policy terms and conditions.” Existing claims processes remain unchanged . …….”
The complainant stated that he is ready to accept the clause. Since he is 68 yrs of age, other Companies
will not admit due to overage. He requests Ombudsman to take immediate steps.
2. The Respondent Insurer entered appearance and filed a self contained note. It is submitted that Mr.
Ramakrishnan V. (the “Complainant/Insured”) submitted an Enrolment Form bearing number CB20346448
proposing the issuance of a “Group Assurance Health Plan” Policy which has been specially customized for
the customers of CANARA BANK to Apollo Munich Health Insurance Co. Ltd. (“Company”) proposing to
insure health treatment with sum assured of Rs.2,00,000/-. The Complainant had submitted the Enrolment
Form after going through the terms and conditions of the policy. The details of the Policy were also
explained to him by the insurance agent/sales representative. It is pertinent to mention herein that the
Complainant had full knowledge of the terms and conditions of the Policy and only after going through the
application for Insurance, thoroughly and properly, had submitted the Enrolment Form. That believing the
above said declaration, information and details provided including the medical history by the Proposer in
the EF to be true, correct and complete in all respect, giving due credence to the under writing norms of
Company, a Policy No. 120100/12586/2019/A016466/PE01851365 was issued to the Complainant for a
period commencing from 15-11-2019 till 14-11-2020.
That it is further submitted that the Policy Kit containing all relevant documents were duly received by the
Policyholder thereby giving an opportunity to Policyholder to verify and examine the benefits, terms and
conditions of the Policy taken by him. It is pertinent to submit that the Complainant/Proposer never
approached the Company stating that any information given in the documents in the Policy Kit was
incorrect or any term and condition therein is not understandable or acceptable to her from the receipt of
the policy document. As no objection was received from the Complainant, therefore the Complainant is
strictly bound by the terms and conditions of the policy.
That the Policy of the Complainant was due for renewal on 14-11-2020. It is submitted that the
complainant vide mail dated 23-10-2020 had approached the Answering Respondent Company for
the renewal of his Policy year 2020-2021. The Complainant was informed by the Answering
Respondent vide mail dated 23-10-2020 that the partnership agreement of Canara Bank with
HDFC ERGO Health Insurance has come to an end and the master policy of Group Assurance
Health Plan and Group Personal Accident Insurance Plan will no longer be available in the market.
Also, the Complainant was informed that all the existing customers were given the opportunity to
migrate to the Answering Respondent’s Retail health insurance plan namely Optima Restore (<65
years) and Optima Senior (>65 years) Plans subject to the Underwriting Guidelines of the
Answering Respondent. It is further submitted that the Complainant was informed that his Policy
No. PE01851365which was due for renewal on 14-11-2020 and he had an option to migrate to
Answering Respondent’s Retail health insurance plan namely Optima Senior with continuity
benefits of waiting periods subject to our medical underwriting guidelines and revised renewal
premium. Along with the mail, Portability from, Optima Senior proposal form, brochure, policy
wordings etc. were also sent to the Complainant and the Complainant was requested to fill and
submit them before the expiry of the grace period of 30 days for issuance of the Retail Health
Policy. The issuance of the policy was subject to the Answering Respondent’s underwriting
guidelines.
That it is submitted that on perusal of the documents submitted by the Complainant it was noted
that the Complainant had past history of Myocardial Infraction and hence the Portability was
denied to the Complainant as per the Underwriting guidelines of the Answering Respondent and
the same was communicated to the Complainant vide mail dated 26-10-2020. It is submitted that
the Complainant had opportunity to port his Group Health Policy to also approach Canara Bank
for porting of the Master policy with other insurer appointed by Canara Bank.
That as per the IRDA Guidelines on and Migration and Portability of Health Insurance Policies
dated 01-01-2020, migration from Group Health Insurance Policies to Individual Policies will be
subject to Medical Underwriting. It is submitted that in the present case the Complainant was also
given the option to migrate his Policy from Group to Individual Policy but the Policy was not issued
as per the Underwriting guidelines of the Company. Hence, the Answering Respondent is not
liable to issue any Individual Policy to the Complainant.
It is submitted that the Company has never misrepresented or misguided the Complainant. It is submitted
that the Company has acted in accordance with the terms and conditions.
3. I heard the Complainant and the Respondent Insurer. The Complainant submitted that he had to get two
stents placed, on 4/1/2020, during the policy period. The Ins. Co. settled his claim. His policy was due for
renewal on 14/11/2020 , but the Ins. Co. refused to renew. He wants renewal of the policy. His claims have
not arisen out of any Pre existing diseases. The Respondent Insurer submitted that the particular Group
Policy is no longer in the market and the tie up with the Bank does not exist any more. Due to the
complainant’s history of Myocardial Infarction of 2020, the policy was not renewed based on Company’s
underwriting guidelines.
4. I have heard both the sides and perused the documents. The complainant had availed Group Assurance
Health Plan and Group Personal Accident Insurance through the arrangement between Canara Bank and
the erstwhile Apollo Munich Health Insurance Co. Ltd. The respondent insurer had informed all its policy
holders under this Master policy arrangement, about merger of Apollo Munich Health Insurance Co. Ltd.
with HDFC ERGO Health Insurance, vide a Notice issued in Jan, 2020, in which the following was
mentioned: “ There will be no changes in your policy terms and conditions as detailed in your policy
document. On renewal all continuity benefits shall be available as per existing policy terms and
conditions.”
The Complainant’s policy was due for renewal on 14/11/2020, by when , the respondent insurer’s
partnership agreement with Canara Bank had come to an end and as a result of which , the master policy
of Group Assurance Health Plan and Group Personal Accident Insurance Plan are no longer available in the
market.
The Complainant was informed by the respondent insurer that all the existing customers were given the
opportunity to migrate to the Respondent’s Retail Health Insurance Plan, namely Optima Restore (<65
years) and Optima Senior (>65 years), subject however, to the Underwriting Guidelines of the Respondent.
The respondent Insurer has settled the claim of the Complainant and based on the claim experience and
the underwriting guidelines, the Respondent Insurer did not offer migration/renewal of the policy .
It is learnt that Canara Bank has Group Policy arrangement with TATA AIG and Bajaj Allianze General
Insurance Co. The Complainant was informed at the Hearing, to approach Canara Bank, for porting his
policy within the new arrangement for master Policy with either of the Ins. Cos. and avail continuity
benefits. The Complainant may therefore, do so and avail the continuity benefits.
In the result, an AWARD is passed for Dismissal of the complaint.
Dated this the 18th day of January, 2021.
Sd/-
(POONAM BODRA)
INSURANCE OMBUDSMAN
AWARD NO.IO/KOC/A/HI/0365/2020-2021
PROCEEDINGS OF
THE INSURANCE OMBUDSMAN, KOCHI
(UNDER RULE NO. 13 1(b) READ WITH RULE 14 OF
THE INSURANCE OMBUDSMAN RULES, 2017)
Complaint No. KOC-H-051-2021-0537
PRESENT: Ms. POONAM BODRA
INSURANCE OMBUDSMAN, KOCHI.
AWARD PASSED ON 22.01.2021
1.
Name and Address of the complainant
:
Mr. Tony Chacko,
SWO (A), 227451, Corporation Bank, (now Union
Bank of India), Mezhuveli P.O, Pathanamthitta
689507
2.
Policy Number
:
5001002819P111087388
3.
Name of the Insured
:
Mr. Ethan Tony and Mrs. Meena Chacko
4.
Name of the Insurer
:
The United India Insurance Co. Ltd.
5.
Date of receipt of Complaint
:
23.10.2020
6.
Nature of complaint
:
Rejection of mediclaim
7.
Amount of relief sought
:
--
8.
Date of hearing
:
08.01.2021
9.
Parties present at the hearing
c. For the Complainant
:
Mr. Tony Chacko (online)
d. For the Insurer
:
Ms. Srijani S(online)
AWARD
This is a complaint filed under Rule 13 1(b) read along with Rule 14 of the Insurance Ombudsman Rules,
2017. The complaint is regarding rejection of mediclaim. The complainant, Mr. Tony Chacko is the
policyholder.
1. Averments in the complaint are as follows:
The Complainant stated that he has two complaints regarding nonpayment/short payment of the health
claim of his son and that of his mother. He is having a IBA group medical insurance policy (Corporation
Bank/United India Insurance Ltd.). During Nov, 2019, all claim related papers of his son`s treatment were
submitted with the respondent insurer except for the original X- ray film and the Doctor`s prescription,
which were lost. The claim amount of Rs.13,649/-, was denied due to the non availability of X- ray film of
Rs.600/-. Secondly his mother`s claim for Rs.10,191/-, which was settled as cashless in February,2020, with
a short payment for the MRI scan taken outside the hospital. Later the claim form with original MRI film
was send, but yielded no result. He had pleaded for reimbursing of the claimed amount of his son &
mother.
2. The Respondent Insurer entered appearance and filed a self contained note. It is submitted that
a group Mediclaim policy bearing no.5001002819P111087388, was issued to the Corporation
Bank employees for the period 01-Oct-2019 To 30-Sep-2020. The complainant`s 5-year old
son, who was the patient was included by the Corporation Bank in the list of the insured
persons. He was diagnosed with Bronchopneumonia and was admitted for the period 11.10.2019
to 16.10.19, in the hospital. A claim amount for Rs. 13,649/-, submitted was denied stating the
following requirements:
1. The advice for admission from treating doctor- prescription,
2. Original report of X-ray,
3. Claim Intimation copy duly received by the respondent insurer, if the same was not reported,
and to clarify the reason, (Intimation must be submitted within 48 Hrs. from the admission date as
per terms & condition of the Policy,
4 KYC details of the Employee (Photo ID proof & Address proof)
5. Photo ID proof of the patient
6. Doctor`s prescription in original against all consultations fees
7. The original proper medicine bills from the Hospital.
As the TPA received only part compliance of the above said queries, a further letter was send seeking the
following:-
1. Original report of X-ray
2. Cause of delay in submission of Claim Intimation
3. Doctor`s prescription in original against all consultation fees
Since these queries were not complied with, the claim was closed.
3. I heard the Complainant and the Respondent Insurer. The Complainant submitted that he had two
claims: 1). His son, 5years old, who was admitted at the Sanjos Hospital, Alappuzha, with
Brochopneumonia, from 11.10.2019 to 16.10.2019. The claim bills for Rs,13,469/-, when submitted was
denied stating that Xray films & Doctor`s prescriptions were not submitted. The complainant had informed
the respondent insurer that he had lost both the X-ray film as well as the Doctor`s prescription. As the
report of X-ray was traced out, it would be submitted with the respondent insurer for the reimbursement
of then claim amount 2).His Mother, 59 years old, who was admitted at the Providence hospital,
Alappuzha, with Hamstring Tendinitis with Partial Tear Right Lower Limb, Intravertebral Disc Prolapse , for
the period 3.2.20 to 6.2.20. The hospital claim bills amounting to Rs.10,191/-, was short settled since the
MRI-scan taken outside the hospital which forms part of the treatment process was not considered . The
complainant prayed for considering his claims. The respondent insurer submitted that since the following
documents like original X-ray report, Doctor`s prescription, cause of delay were unanswered, the claim was
closed.
4. I heard the complainant and the respondent insurer and had gone through the reports submitted. In
this complainant where the respondent insurer had closed the claim of the complainant’s son`s treatment
for Bronchopneumonia, for want of X-ray report and doctor`s prescription and the nonpayment of MRI
expenses taken outside the hospital, forming part of his mother`s treatment for Hamstring Tendinitis with
Partial Tear Right Lower Limb, Intravertebral Disc Prolapse, it is agreed for settlement of the admissible
amount . The complainant has informed during the hearing on 08.0.21, that he had traced out the report
of X-ray pertaining to his son`s treatment and would submit the same. The complainant therefore has to
submit the original report of X-ray, treatment bills & records pertaining to his son as well as the bills for
the MRI scan taken outside the hospital but forms part of his mother`s treatment. The respondent insurer
is directed to pay the admissible amount as per the policy terms & conditions subject to the submission of
treatment bills/records.
In the result, an award is passed, directing the Respondent Insurer to pay the admissible amount as per the
terms and conditions of the policy subject to submission of original report of X-ray ,bills & records of
treatment pertaining to his son and the bills/records for the MRI scan taken outside the hospital but forms
part of his mother`s treatment, within the period mentioned hereunder. No cost.
As prescribed in Rule 17(6) of Insurance Ombudsman Rules, 2017, the Insurer shall comply with the award
within 30 days of receipt of the award and intimate compliance of the same to the Ombudsman.
Dated this the 22
nd
day of January, 2021.
Sd/-
(POONAM BODRA)
INSURANCE OMBUDSMAN
AWARD NO.IO/KOC/A/HI/0367/2020-2021
PROCEEDINGS OF
THE INSURANCE OMBUDSMAN, KOCHI
(UNDER RULE NO. 13 1(b) READ WITH RULE 14 OF
THE INSURANCE OMBUDSMAN RULES, 2017)
Complaint No. KOC-H-051-2021-0556
PRESENT: Ms. POONAM BODRA
INSURANCE OMBUDSMAN, KOCHI.
AWARD PASSED ON 25.01.2021
1.
Name and Address of the complainant
:
Mr. V Damodaran,
E/156 Federal Park, Vennala, Ernakulam, Kochi
682028
2.
Policy Number
:
50010002819P111919556
3.
Name of the Insured
:
Mr. V Damodaran
4.
Name of the Insurer
:
The United India Insurance Co. Ltd.
5.
Date of receipt of Complaint
:
30.11.2020
6.
Nature of complaint
:
Rejection of mediclaim
7.
Amount of relief sought
:
--
8.
Date of hearing
:
08.01.2021
9.
Parties present at the hearing
(iv) For the Complainant
:
Mr. Damodaran V (online)
(v) For the Insurer
:
Ms. Srijani S(online)
AWARD
This is a complaint filed under Rule 13 1(b) read along with Rule 14 of the Insurance Ombudsman Rules,
2017. The complaint is regarding rejection of mediclaim. The complainant, Mr. V Damodaran is the
policyholder.
1. Averments in the complaint are as follows:
The Complainant stated that his claim under the IBA policy(United India Insurance Co. Ltd. / The Federal
Bank Ltd.) was repudiated stating that the treatment took was for diagnostic purposes. It is stated that the
complainant lost 12kgs weight in a matter of 30-40days. The complainant`s urine was having protein and
blood particles. In order to start the treatment, it was inevitable to know the exact reasons. All the
examinations were in tune with the treatment given. Some medications cause reactions on certain
functions of the body and there were a team of doctors for taking care of such aberrations. The quantum
of relief sought is Rs.1,55,081.-. DOA :9.8.20, DOD:28.8.20.
2. The Respondent Insurer entered appearance and filed a self contained note. It is submitted that a group
Mediclaim policy was issued to the Federal Bank Retiree`s without domiciliary benefit –Policy
No. 5001002819P111919556 for period 01-Nov-2019 To 31-Oct-2020. The complainant was included
by Federal Bank Ltd., in the list of the insured persons. The complainant was the patient in the claims which
the complaint has been made. The claim details are as follows:-
1
TPA ID Card Number
Koc-Ui-I0578-002-0000148-A
2
Name & Address of the Hospital
Amrita Institute Of Medical Sciences &
Research Centre
3
Date of Admission
09.08.2020
4
Type of Claim
Reimbursement
5
Nature of Illness
Renal Failure, Vasculitis, MYP, Hemorrhoids
6
Total Amount Claimed
Rs. 155081.00.-
On scrutiny of the claim documents by TPA, it was found that the patient was diagnosed with
Renal Failure, Vasculitis, MYP, Hemorrhoids. It has been informed that the hospitalization was
mainly for diagnosis purposes. Accordingly the claims were repudiated under policy exclusion
clause 4.7, of the policy which reads as under :Charges incurred at Hospital or Nursing Home
primarily for diagnosis x-ray or Laboratory examinations or other diagnostic studies not consistent
with or incidental to the diagnosis and treatment of positive existence of presence of any ailment,
sickness or injury, for which confinement is required at a Hospital / Nursing Home, unless
recommended by the attending doctor.
3. I heard the complainant and the respondent insurer. The complainant submitted that he had
lost about 12kgs of his body weight in a matter of 30 to 40days. He had protein and blood
particles in his urine. It was therefore necessary to conduct all tests to find out the exact reasons
in order to start the treatment. Therefore with the treatment given was based on the tests
conducted. There were also some medications which cause reactions on certain functions of the
body and a team of doctors who were taking care of these. Hence his hospitalizations claim of
Rs.1,55,081/-for the period 9.8.20 to 28.8.20, which was denied by the respondent insurer is to
be settled. The respondent insurer submitted that on scrutiny of the claim documents the patient
was diagnosed with Renal Failure, Vasculitis, MYP, Hemorrhoids. The hospitalization was mainly
for diagnosis purposes. Hence the claim was denied as per policy terms & conditions. Policy Clause
4.7- Charges incurred at Hospital or Nursing Home primarily for diagnosis x-ray or Laboratory
examinations or other diagnostic studies not consistent with or incidental to the diagnosis and
treatment of positive existence of presence of any ailment, sickness or injury, for which
confinement is required at a Hospital / Nursing Home, unless recommended by the attending
doctor.
4. I heard the complainant and the respondent insurer and had gone through the records submitted by
them. I had considered the following factors to arrive at a just and fair decision:- 1). The complainant was
hospitalized with sudden weight loss. 2).He was diagnosed with Renal Failure, Vasculitis, MYP,
Hemorrhoids. 3). All evaluations/investigations conducted were all necessary for diagnosing the illness for
providing the proper treatment 4). The doctor`s certificate indicates that the complainant was diagnosed
as IgA Nephropathy (Primary/Secondary) with systemic vasculities – suggestive of large vasculities. On
analyzing the above said factors the complainants hospital admission is justified and
evaluations/investigations were conducted as part of his treatment . Therefore, in this case the respondent
insurer has to pay the admissible amount of Rs.1,41,815/-, as per the policy terms & conditions , on
submission of bills/records.
In the result, an award is passed, directing the Respondent Insurer to pay the admissible amount of
Rs.1,41,815/-, as per the policy terms & conditions , on submission of bills/records , within the period
mentioned hereunder. No cost.
As prescribed in Rule 17(6) of Insurance Ombudsman Rules, 2017, the Insurer shall comply with the award
within 30 days of receipt of the award and intimate compliance of the same to the Ombudsman.
Dated this the 25
th
day of January, 2021.
Sd/-
(POONAM BODRA)
INSURANCE OMBUDSMAN
AWARD NO.IO/KOC/A/HI/0382/2020-2021
PROCEEDINGS OF
THE INSURANCE OMBUDSMAN, KOCHI
(UNDER RULE NO. 13 1(b) READ WITH RULE 14 OF
THE INSURANCE OMBUDSMAN RULES, 2017)
Complaint No. KOC-H-051-2021-0531
PRESENT: Ms. POONAM BODRA
INSURANCE OMBUDSMAN, KOCHI.
AWARD PASSED ON 29.01.2021
1.
Name and Address of the complainant
:
Mrs. Rajalekshmi Devi S,
S-A , Jomer Haven, Illam Road, Ernakulam-682016
2.
Policy Number
:
5001002819P112203988
3.
Name of the Insured
:
Mrs. Rajalekshmi Devi S
4.
Name of the Insurer
:
The United India Insurance Co. Ltd.
5.
Date of receipt of Complaint
:
17.11.2020
6.
Nature of complaint
:
Rejection of mediclaim
7.
Amount of relief sought
:
--
8.
Date of hearing
:
07.01.2021
9.
Parties present at the hearing
● For the Complainant
:
Ms. Rajalekshmi Devi S (online)
● For the Insurer
:
Ms. Sreejani (online)
AWARD
This is a complaint filed under Rule 13 1(b) read along with Rule 14 of the Insurance Ombudsman Rules,
2017. The complaint is regarding rejection of mediclaim. The complainant, Mrs. Rajalekshmi Devi S is the
policyholder.
1. Averments in the complaint are as follows:
The Complainant stated that she is a retired Indian Bank employee. She was admitted in Hospital from
12/12/19 to 14/12/19 and her claim for Rs. 15,348/- was not paid. She later submitted Doctor’s
Certificate, with no response. No positive action was taken despite her many mail and telephones. She
requests the Ombudsman to redress her grievance.
2. The Respondent Insurer entered appearance and filed a self contained note. It is submitted that
they have issued a group Mediclaim policy to Indian Bank retirees without domiciliary
benefit : 5001002819P112203988 for period 01-Nov-2019 To 31-Oct-2020. Rajalekshmi Devi S is
included by Indian Bank in the list of insured persons.
Rajalekshmi Devi S was the patient in the claims regarding which the complaint has been made. The
complaint is pertaining to claim number TPA claim number 20200102B005RH37697 . On receiving the
complaint copy , the claims are scrutinized by the servicing TPA .
The complaint arose due to repudiation of the claims. The insured patient Ms. Raja Lekshmi Devi S was
admitted at Medical Trust Hospital from 12/12/2019 to 14/12/2019 as a case of LRTI, oral candidiasis with
Rheumatoid arthritis with hyperactive airway disease with Hypothyroidism with Anemia. The claimed
amount was Rs. 15,438/-. As per the discharge summary the insured patient was admitted for the purpose
of diagnostic and conservative management, and no therapeutic treatment were given at the time is
hospitalization.
As per doctor’s opinion the disease/illness does not warrant hospitalization and the treatment could have
been done as an OPD patient even though it was converted into hospitalization for more than 24 hours.
Clause 4.7 Exclusion of the policy reads as under :
Charges incurred at Hospital or Nursing Home primarily for diagnosis x-ray or Laboratory examinations or
other diagnostic studies not consistent with or incidental to the diagnosis and treatment of positive
existence of presence of any ailment, sickness or injury, for which confinement is required at a Hospital /
Nursing Home, unless recommended by the attending doctor.
Accordingly the claims were repudiated.
3. I heard the Complainant and the Respondent Insurer. The Complainant submitted that she is a retired
Bank employee and she had incurred over Rs 15,000/- for her hospitalization but the Ins. Co. rejected her
claim stating that she need not have been hospitalized. Decision whether to be admitted in hospital or not
is to be taken by the Doctor and the Ins. Co. is not competent to decide. Her condition was bad and she
was very weak and so was admitted into the hospital. She appealed but to no avail. The Respondent
Insurer submitted that the policy was opted by the complainant with Sum Insured of Rs. 4 lakhs . The policy
is without Domiciliary Hospital benefit. On admission, the complainant was afebrile and she was treated
with only oral medicines , which was possible even as an out-patient.
4. I have heard both the sides and perused the documents. It is observed from the Discharge Summary
that the complainant is a k/c/o rheumatoid arthritis on immuno-suppressants , HAAD and hypothyroidism,
and admitted with fever for past 1 week associated with generalized body pain and occasional cough. It is
further observed that she was afebrile and Clinically normal at admission. The treatment she took in the
hospital is of the nature of Out-patient treatment. It is evident that there was no need of Hospitalization.
The claim is therefore, not tenable.
In the result, an AWARD is passed for Dismissal of the complaint.
Dated this the 29
th
day of January 2021
Sd/-
(POONAM BODRA)
INSURANCE OMBUDSMAN
AWARD NO. IO/KOC/A/HI/0383/2020-2021
PROCEEDINGS OF
THE INSURANCE OMBUDSMAN, KOCHI
(UNDER RULE NO. 13 1(b) READ WITH RULE 14 OF
THE INSURANCE OMBUDSMAN RULES, 2017)
Complaint No. KOC-H-050-2021-0533
PRESENT: Ms. POONAM BODRA
INSURANCE OMBUDSMAN, KOCHI
AWARD PASSED ON 29.01.2021
1
.
Name and Address of the complainant
:
Mr. Ahamed
Shareef,
Jakiparambil
House,
Kizhuparamba
P O, Areecod
via,
Malapuram
Kerala -
673636
2
.
Policy Number
:
440100/48/20
19/3129
3
.
Name of the Insured
:
Mr. Ismail Y P
4
.
Name of the Insurer
:
The Oriental
Insurance Co.
Ltd.
5
.
Date of receipt of Complaint
:
09.11.2020
6
.
Nature of complaint
:
Rejection of
mediclaim
7
.
Amount of relief sought
:
--
8
.
Date of hearing
:
07.01.2021
9
.
Parties present at the hearing
g) For the
Complainant
:
Mr. Ahamed
Shareef
(online)
h) For the Insurer
:
Ms. Maya
Satish (online)
AWARD
This is a complaint filed under Rule 13 1(b) read along with Rule 14 of the Insurance Ombudsman Rules,
2017. The complaint is regarding rejection of mediclaim. The complainant, Mr. Ahamed Shareef is the son
of the policyholder.
1. Averments in the complaint are as follows:
The Complainant stated that his father was hospitalized in Meitra Hospital for treatment of heart ailment.
His claim was not settled by the Ins. Co. There was no reply to his letter to Griev. Cell. He requests the
Ombudsman to get his claim settled.
2. The Respondent Insurer entered appearance and filed a self contained note. It is submitted that Mr
Ismail Y P who is covered under the GMC Policy No.440100/48/2019/3129 of M/s Apollo Tyres, Perambra,
had lodged a claim with M/s Vidal Health TPA Pvt. Ltd under the above policy for the treatment at Meitra
Hospital for Infra Renal Aortic Aneurys, HTN, DM2, RAD 07.11.2020.
According to the discharge summary for the hospitalisation, the patient is a known case of Large-renal
Aortic Aneurysm- status post endovascular aneurysm repair abdominal aorta on 13.02.2018. He was
admitted for CT aorotogram and further management.
As per the policy conditions “Expenses incurred at Hospital or Nursing Home primarily for
evaluation/diagnostic purposes which is not followed be active treatment for ailment during the
hospitilasation period” would not become payable.
Apart from investigations/CT aortogram the discharge summary and medical records do not disclose any
active line of treatment undergone during the hospitalisation and hence the rejection of the claim is in
order.
As per policy clause 4.10 the claim was repudiated. In view of the above, It is prayed, that the Hon.
Ombudsman may uphold the decision of the company and dismiss the complaint.
3. I heard the Complainant and the Respondent Insurer. The Complainant submitted that his father was
admitted in hospital for treatment but the Ins. Co. did not settle the claim. . The Respondent Insurer
submitted that the patient was hospitalized only for a day and only investigations were carried out and
hence the claim is not payable.
4. I heard both the sides and perused the documents. It is observed from the Discharge Summary and the
detailed Inpatient bills that not only investigations were done but the complainant’s father was given
treatment which included costly injections. I am of the opinion therefore that the hospitalization was not
solely for investigations but that there was active line of treatment. The claim is tenable. The Admissible
Claim Amount is Rs. 15,506/- It is also observed that the Regional Office of the Respondent Insurer has
replied to the Griev. Letter of the Complainant, copy of which the complainant himself has attached to his
Complaint.
In the result, an award is passed, directing the Respondent Insurer to pay an amount of Rs. 15,506/- ,
within the period mentioned hereunder. No cost.
As prescribed in Rule 17(6) of Insurance Ombudsman Rules, 2017, the Insurer shall comply with the award
within 30 days of receipt of the award and intimate compliance of the same to the Ombudsman.
Dated this the 29
th
day of January 2021.
Sd/-
(POONAM BODRA)
INSURANCE OMBUDSMAN
AWARD NO. IO/KOC/A/HI/0384/2020-2021
PROCEEDINGS OF
THE INSURANCE OMBUDSMAN, KOCHI
(UNDER RULE NO. 13 1(b) READ WITH RULE 14 OF
THE INSURANCE OMBUDSMAN RULES, 2017)
Complaint No. KOC-H-050-2021-0530
PRESENT: Ms. POONAM BODRA
INSURANCE OMBUDSMAN, KOCHI
AWARD PASSED ON 29.01.2021
1.
Name and Address of the complainant
:
Mr. Ginsen,
Pallissery House, East Kombara,
Irinjalakuda, Thrissur - 680121
2.
Policy Number
:
440100/48/2019/3129
3.
Name of the Insured
:
Mr. Ginsen
4.
Name of the Insurer
:
The Oriental Insurance Co. Ltd.
5.
Date of receipt of Complaint
:
09.11.2020
6.
Nature of complaint
:
Rejection of mediclaim
7.
Amount of relief sought
:
--
8.
Date of hearing
:
07.01.2021
9.
Parties present at the hearing
l. For the Complainant
:
Mr. Ginsen P(online)
m. For the Insurer
:
Ms. Maya Satish (online)
AWARD
This is a complaint filed under Rule 13 1(b) read along with Rule 14 of the Insurance Ombudsman Rules,
2017. The complaint is regarding rejection of mediclaim. The complainant, Mr. Ginsen is the policyholder.
1. Averments in the complaint are as follows:
The Complainant stated that his wife was under treatment at Amala Hospital, Thrissur, from 22/ 7/19 to
24/7/19. He submitted all the claim papers to the Ins. Co. but they rejected his claim. There was no reply
to his Griev. Letter. He requests the Ombudsman to get his claim settled.
2. The Respondent Insurer entered appearance and filed a self contained note. It is submitted that Mr
Ginsen who is covered under the GMC Policy No.440100/48/2019/3129 of M/s Apollo Tyres, Perambra,
had lodged a claim with M/s Vidal Health TPA Pvt. Ltd under the above policy for the treatment of his wife
at Amala Hospital for recurrent cough, dyspnea and hemoptsis since 5 years.
According to the discharge summary for the hospitalization, the patient underwent various evaluations
and CT thorax was taken. Bronchoscopy was suggested but the patient was not willing for the same. The
Patient was evaluated and diagnosed with hemoptsis for evaluation.
As per the policy conditions “Expenses incurred at Hospital or Nursing Home primarily for
evaluation/diagnostic purposes which is not followed by active treatment for ailment during the
hospitalization period” would not become payable.
Apart from investigations/diagnosis, the discharge summary and medical records do not disclose any active
line of treatment undergone during the hospitalisation and hence the rejection of the claim is in order.
As per policy clause 4.10 the claim was repudiated. In view of the above, it is prayed, that the Hon.
Ombudsman may uphold the decision of the company and dismiss the complaint.
3. I heard the Complainant and the Respondent Insurer. The Complainant submitted that his wife had
bleeding through her nose and went to hospital for check up and was admitted there and her tests
revealed that she was normal , she was treated on medicines and discharged. The Respondent Insurer
submitted that during the hospitalization , only investigations were carried out and oral medicines only
were given.
4. I have heard both the sides and perused the documents. The complainant’s wife was diagnosed for
hemoptysis for evaluation/ hypothyroidism. She is stated to have Hemoptysis since 5 yrs. It is observed
that she underwent investigations and was treated only on oral medicines. The treatment could have been
taken on OPD basis. As per clause 4.10 of the policy, expenses incurred at Hospital or Nursing Home
primarily for evaluation/diagnostic purposes which is not followed by active treatment for ailment during
the hospitalization period” is an Exclusion . The claim is therefore, not tenable. It is further observed that
the Regional Office of the respondent insurer has replied to the Griev. letter of the Complainant on
8/9/2020 , copy of which the complainant himself has attached to his Complaint.
In the result, an AWARD is passed for Dismissal of the complaint.
Dated this the 29
th
day of January 2021
Sd/-
(POONAM BODRA)
INSURANCE OMBUDSMAN
AWARD NO.IO/KOC/A/HI/0385/2020-2021
PROCEEDINGS OF
THE INSURANCE OMBUDSMAN, KOCHI
(UNDER RULE NO. 13 1(b) READ WITH RULE 14 OF
THE INSURANCE OMBUDSMAN RULES, 2017)
Complaint No. KOC-H-018-2021-0522
PRESENT: Ms. POONAM BODRA
INSURANCE OMBUDSMAN, KOCHI.
AWARD PASSED ON 29.01.2021
1.
Name and Address of the complainant
:
Mrs. Kanthy M,
Malanivas, Kadukkamkunnam, Malampuzha,
Palakkad-678651
2.
Policy Number
:
120100/12001/2018/AO12706/821
3.
Name of the Insured
:
Mr. U P Ramachandran
4.
Name of the Insurer
:
HDFC ERGO General Insurance Company Ltd.
5.
Date of receipt of Complaint
:
16.11.2020
6.
Nature of complaint
:
Denial of mediclaim
7.
Amount of relief sought
:
--
8.
Date of hearing
:
13.01.2021
9.
Parties present at the hearing
d. For the Complainant
:
Mrs. Kanthy M (online)
e. For the Insurer
:
Mr. Sachin Verma(online)
AWARD
This is a complaint filed under Rule 13 1(b) read along with Rule 14 of the Insurance Ombudsman Rules,
2017. The complaint is regarding denial of mediclaim. The complainant, Mrs. Kanthy M is the
policyholder.
1. Averments in the complaint are as follows:
The Complainant submitted that her husband was holding a policy with the respondent insurer (Earlier
Appolo Munich) with policy No.120100/ 12001/ 2018/ A012706/821. Her husband was hospitalized at SAI
Hospital Olavakkode during 18.01.2020 and 30.01.2020. He was diagnosed of TB of spine and was given
suitable treatment. He was never in his life diagnosed of this illness before. The claim was denied stating
that he had undergone a CABG Surgery in 2003 and was diagnosed of BPH condition in 2014. The first
policy was for the period from 18.03.2016 to 17.03.2017, the second, third and fourth renewals were done
in succeeding years namely, 2017-18, 2018-19 and 2019-20. No single instance of claim arising from
hospitalization has ever been there in the policy for medical conditions directly or indirectly related to the
PED conditions which the complainant was alleged to conceal in any of the four years. Even the
hospitalization in question was for a totally unconnected and a purely fresh medical condition called TB of
spine.
At the time joining the Health insurance scheme in 2016, the complainant had specifically told the
representative of Canara Bank ( Appolo Munich insurance scheme)that her husband had undergone CABG
operation during 2003 and that he is diagnosed of BPH(Prostate disorder) in 2014. The representative
assured her that pre-existing conditions will be covered under the policy after a waiting period of 36
months. She has not hidden any facts as alleged by the respondent insurer. The Insurer chose not to
conduct medical checkup before entry in to the scheme, knowing well that they are senior citizens and that
geriatric population is likely to have adverse claims history of one sort or the other. The agent asked her to
sign on the proposal form filled by him at the time of joining as per advice given. The agent maintained that
these adverse conditions will be covered after 36 months of operation of the policy and these facts of PED
need no specific mentioning. Of course, she is not able to produce any documented or recorded evidence
for the version of the agent.
Three years have already been elapsed and the policy was running the fourth year of its term, namely 18
March 2019 to 17 March 2020. The hospitalization in question is no way connected to any issue directly or
indirectly related to the said medical condition or any of its complications. The respondent insurer is taking
the excuse of PED conditions only to deny her legitimate claim arising from an acute medical condition
which is not related in any way whatsoever either the heart surgery or prostate disorder. The claim is
denied on the un justified grounds of non-disclosure of PED and to top it all, they arbitrarily cancelled the
policy in the fourth year of its operation. It is humbly and respectfully prayed that her claim may be
admitted in its genuineness and it is also requested that the arbitrary act of cancelling the policy in the
fourth year of its term may be reversed. She wishes to escalate the matter to this forum in the hope that
the claim amy be reconsidered on principles of fair ethics in commercial practices and honoring customer
rights and privileges.
2. The Respondent Insurer entered appearance and filed a self-contained note. It is submitted that Mrs.
Kanthy M (the “Proposer”) submitted duly filled up Enrolment Form bearing number CB10201717 dated
16-03-2016 proposing the issuance of an “Easy Health Group Insurance” Policy which has been specially
customized for the customers of CANARA BANK to Apollo Munich Health Insurance Co. Ltd. proposing to
insure her Husband Mr. Ramachandran UP with sum assured of Rs.5,00,000/-. The details of the Policy
were also explained to her by the insurance agent/sales representative. It is pertinent to mention herein
that the Complainant had full knowledge of the terms and conditions of the Policy and only after going
through the application for Insurance, thoroughly and properly, had submitted the Enrolment Form. That
further to above, the Proposer in the declaration paragraph of the Enrolment Form dealing with
“Declaration & Warranty on behalf of all persons proposed to be insured” has agreed and declared to the
following:-
“I/we hereby declare, on my behalf and on behalf of all persons proposed to be insured that the
above statements, answers and/or particulars given by me are true and complete in all respects to
the best of my knowledge”.
That believing the above said declaration, information and details provided including the medical
history by the Proposer in the EF to be true, correct and complete in all respect, giving due
credence to the under writing norms of Company, a Policy No.
120100/12001/2016/A005425/PE00184136 was issued to the Insured namely Mr. Ramachandran
UP for a period commencing from 18-03-2016 till 17-03-2017. It is submitted that the Policy was
further renewed for the period till 17-03-2020. It is submitted that the factum of renewal
essentially entails that the Complainant was fully aware of the applicable terms and conditions of
the insurance contract and further subscribed to the same by way of renewing the policy time and
again. That it is further submitted that the Policy Kit containing all relevant documents along with
the Enrolment Form were duly received by the Proposer thereby giving an opportunity to
Proposer to verify and examine the benefits, terms and conditions of the Policy taken by the
Proposer. It is pertinent to submit that the Complainant/Proposer never approached the Company
stating that any information given in the documents in the Policy Kit was incorrect or any term
and condition therein is not understandable or acceptable to her within from the receipt of the
Policy document. As no objection was received from the Complainant, therefore the Complainant
is strictly bound by the terms and conditions of the policy.
That it is submitted that during the continuation of the Policy period, the Complainant
approached the Answering Respondent to avail Cashless Facility Request vide Cashless Claim ID:
714232 for the hospitalization of the Insured namely Mr. Ramachandran U P from 18-01-2020 till
30-01-2020 at SAI Hospital. The Complainant herein was diagnosed with Disseminated TB Spine.
On perusal of the documents received with Cashless documents, it was noted from the Discharge
Summary dated 20-08-2003 and TDC dated 23-01-2020, that the Insured had past history of CAD
since 2003 and BPH since 2014 i.e Prior to the Policy Inception.
In the light of the above noted observation, the Cashless Claim was rejected vide rejection letter
dated 25-01-2020 with reason “ As per the available documents, we have observed that there is
incorrect good health declaration of ___CAD and BPH __________ (ailment) which may have an
impact on policy and hence cashless approval would not be possible at this juncture.”
That post rejection the above mentioned Cashless claim, the Complainant filed Reimbursement
Claim vide Claim ID: 1293327 for an amount of Rs.74,608/- for the above mentioned
hospitalization of the of the Insured namely Mr. Ramachandran U P from 18-01-2020 till 30-01-
2020 at Sai Hospital. The Complainant herein was diagnosed with Disseminated TB Spine.
On perusal of the Discharge Summary, it was again noted that the Insured was mentioned as
known case of Diabetes and CAD (Post CABG). That the Answering Respondent Company sent its
query letter to the Complainant for providing documents for the proper assessment of the claim.
In the light of the observation made during the Cashless claim and Reimbursement Claim, the
Claim of the Complainant was rejected under non-disclosure of material information i.e CAD
(Coronary artery disease) and BPH (Benign prostatic hyperplasia) since 2003 and 2014 i.e. prior to
policy inception i.e prior to the policy inception and the same was intimated to the Complainant
vide letter dated 10-03-2020. That in the light of the above noted non-disclosure of Past history of
CAD (Coronary artery disease) and BPH (Benign prostatic hyperplasia) since 2003 and 2014 i.e.
prior to policy inception, the Answering Respondent also terminated the Policy of the
Complainant and the same was intimated to the Complainant vide its letter dated 06-03-2020.
That it is further submitted that if the Proposer would have disclosed about the past history of
Complainant’s Total Thyroidectomy in the Enrolment form at the time of policy inception, then
the Answering Respondent would not have issued the above mentioned Policy to the
Complainant.
That further it is pertinent to mention here that the claims are paid by any Insurance Company
out of the common pool of funds belonging to all Proposers of the Company which makes it
obligatory upon the Insurance Company to check the admissibility of each claim in strict sense of
the Policy Terms and Conditions before honoring the same in the larger interest of all the Policy
Holders.
It is submitted that the case of the Complainant is squarely covered by the terms of the policy and
the claim was rightly rejected by the Answering Respondent in terms of the Policy. It is
additionally submitted that the Proposer also has the right to understand the workability of the
Policy before Submitting the Enrolment form, it is submitted that the fact that the
Complainant/Proposer had renewed the policy clearly entails that he was aware of the terms and
conditions which governed the Insurance Policy. Further, the claim of the Complainant has been
dealt in accordance with the Insurance Contract and the contents of the preceding paragraphs
may be read as part and parcel of the current paragraph and the same are not repeated here for
the sake of brevity.
It is submitted that the Answering Respondent has never misrepresented or misguided the
Complainant/Proposer. The Answering Respondent has acted in accordance with the terms and
conditions. It is further submitted that the Company is a law abiding Company having immense
reputation and does not indulge in any mala fide acts and conduct or unfair trade practices. As a
matter of fact the Company opts for best ethical practice in consonance with the norms as laid
down by IRDAI. It is also submitted that all communications have been dispatched and delivered
by the Answering Respondent on time. It is further incorrect that the Proposer had disclosed
about the Complainant’s pre-existing medical condition to the Answering Respondent at the time
of availing the said policy.
It is submitted that Complainant’s policy has been cancelled for the concealment of a grave
material fact of the past medical history of Past history of CAD (Coronary artery disease) and BPH
(Benign prostatic hyperplasia) since 2003 and 2014 i.e. prior to policy inception, hence neither the
policy can neither be reinstated nor the Complainant could be given any other benefit. The
Answering Respondent has acted in accordance with the Terms & Conditions and cannot process
a Claim that falls outside the Insurance Contract. All the allegations in the complaint by the
Complainant/Proposer are unwarranted and frivolous.
3. I heard the Complainant and the Respondent Insurer. The Complainant submitted that at the
time of taking the policy in 2016, the complainant had specifically told the representative of
Canara Bank/Appolo Munich insurance Company that her husband had undergone CABG
operation during 2003 and that he is diagnosed of BPH(Prostate disorder) in 2014. The
representative assured her that pre-existing conditions will be covered under the policy after a
waiting period of 36 months. She has not hidden any facts as alleged by the respondent insurer.
The policy was in the fourth year and they have not made any claim till that date. But the
respondent insurer denied the claim stating that the complainant had not revealed the episodes
of CABG and BPH. The Respondent Insurer submitted that while taking the policy the complainant
had submitted a signed proposal form and the declaration in the same. Based on the same a
policy was issued. At the time of cashless claim it was found that the insured was diagnosed with
Disseminated TB Spine. On perusal of the documents, it was noted that the Insured had past
history of CAD since 2003 and BPH since 2014 i.e Prior to the Policy Inception. The details of
coronary artery disease and BPH were not revealed in the proposal form while taking the policy.
Hence the claim was repudiated due to incorrect good health declaration in the proposal form.
Hence the claim was repudiated and the policy was cancelled for concealment of a grave material
fact of the past medical history.
4. I have scrutinized the relevant documents and found that the insured had undergone CABG
Surgery in 2003 and was diagnosed of BPH condition in 2014. In the proposal form there were
many health conditions enquired among which one was ‘Any major surgery (any surgery done
other than those done under local anesthesia) in last 5 years’. The complainant had read and
signed the declaration. “I hereby declare and warrant on my behalf and on behalf of all persons
proposed to be insured that the above statements are true and complete in all respects to the
best of my knowledge”. Upon agreeing to the declaration, the complainant has made an
assurance to the respondent insurer that the persons proposed are in good health condition.
Based on the same the policy was issued. Later when a claim was raised it was exposed to the
insurer that the insured had undergone CABG and BPH before the inception of the policy.
Insurance contract is a contract of utmost good faith. Here the complainant has concealed the
material fact of having preexisting disease, whereby misguided the company in issuing a policy. If
the preexisting ailment was disclosed at the time of issuance of the policy, the respondent insurer
could have taken a decision not to accept the proposal or to load the policy with restrictions. Here
such an opportunity was denied by the complainant. The respondent insurer has repudiated the
claim and cancelled the policy based on the terms and conditions of the policy. As such I do not
want to interfere in to their decision.
In the result, an AWARD is passed for Dismissal of the complaint.
Dated this the 29
th
day of January 2021.
Sd/-
(POONAM BODRA)
INSURANCE OMBUDSMAN
AWARD NO.IO/KOC/A/HI/0387/2020-2021
PROCEEDINGS OF
THE INSURANCE OMBUDSMAN, KOCHI
(UNDER RULE NO. 13 1(b) READ WITH RULE 14 OF
THE INSURANCE OMBUDSMAN RULES, 2017)
Complaint No. KOC-H-055-2021-0538
PRESENT: Ms. POONAM BODRA
INSURANCE OMBUDSMAN, KOCHI.
AWARD PASSED ON 29.01.2021
1.
Name and Address of the complainant
:
Mr. Rajesh P P
Pattathara House, Vyasapuram Road,
Kumbalangi, NR Keltron, Cochin
682007
2.
Policy Number
:
GHI193750063
3.
Name of the Insured
:
Mr. Abhinand P R
4.
Name of the Insurer
:
Aditya Birla Health Insurance Company
Limited
5.
Date of receipt of Complaint
:
16.11.2020
6.
Nature of complaint
:
Denial of mediclaim
7.
Amount of relief sought
:
--
8.
Date of hearing
:
13.01.2021
9.
Parties present at the hearing
b. For the Complainant
:
Mr. Rajesh P P (online)
c. For the Insurer
:
Ms. Manali Shukla (online)
AWARD
This is a complaint filed under Rule 13 1(b) read along with Rule 14 of the Insurance Ombudsman Rules,
2017. The complaint is regarding denial of mediclaim. The complainant, Mr. Rajesh P P is the policyholder.
1. Averments in the complaint are as follows:
The Complainant submitted that he had subscribed ‘Group Active Health” Insurance policy from the
respondent insurer with policy No. GHI193750063 for the period from 06.02.2020 to 05.02.2021. The
policy is family floater covering family including his wife, son and daughter. On 19.08.2020, the
complainant’s son AbhinandP R , Aged 14 was suffering from severe abdominal pain and was diagnosed
with acute Appendicitis at Fathima Hospital and research centre, perumpadappu, Kochi and was later
admitted to Medical Trust Hospital on 19.08.2020 itself. A claim was raised for cashless and the same was
approved for Rs.35,000/-. The complainant’s son was undergoing a course of antibiotics and was
scheduled for appendicectomy surgery. It was at that stage, his bilirubin levels underwent variations and
therefore the surgery was postponed.On investigation it was diagnosed that the patient had a genetic
disorder called “Gilbert Syndrome”, in which the liver does not properly process ‘bilirubin’. He “Gilbert
Syndrome” is a condition that is often discovered by accident such as when someone has ablood test. This
patient was neither diagnosed with this condition nor the family members were aware of it at any point of
time. It is pertinent to note that he was caused Appendicitis not due to the affliction of this inherent
genetic disorder called Gilbert Syndrome. What was discerned from the treating physicians was that the
liver of a patient having Gilbert Syndrome would not be able to process the medicines administered
during perioperative stage as his bilirubin levels would always be above the normal limits. It is for this
reason that the physicians and surgeon refrained from carrying out the procedure on the patient as
subjecting him to perioperative medicines and anesthesia without controlling the bilirubin levels might
cause complications. Since the abdominal pain and infection subsequently subsided due to the effect of
antibiotics, he was discharged after 3 days of treatment on 22.08.2020. The total bill for in patient
hospitalization came up to Rs.26,966.87, which was well within the limit of amount sanctioned for
cashless.
At the time of discharge, the earlier approved claim was denied stating that it was discovered upon
diagnosis that the patient has a Genetic disorder called “Gilbert Syndrome”. The claim rejection letter
refers to Annexure 1 of the policy Permanent exclusions: wherein genetic disorder is mentioned and
hence the claim for reimbursement of the treatment expenses of the insured is rejected. In Section II of
the under the base cover as Clause 1.1 states explicitly that inpatient hospitalization is covered for an
amount of Rupees Three lakhs. Hence there is no reasonable ground in denying the claim. Apart from
Appendectomy with/without drainage is included under the list of “Day care treatments, which are
covered under the policy. Clause 1.2 under the sub-heading ‘in patient hospitalization specifically in
unequivocal terms undertake that the insured will be covered of all medical expenses for day care
treatments. There is no waiting period prescribed for activation of the cover over day care treatments.
The insurance policy permanently excludes payment of any claim for any treatment directly or indirectly
caused by, based on, arising out of , relating to or howsoever attributable to s genetic disorder. The
insured was admitted in the hospital for appendicitis. There is no medical opinion given that Gilbert
Syndrome is a direct cause of appendicitis. Thus there is no legal justification in rejection of the claim for
treatment of a medical condition which was not directly or indirectly caused by, based on, arising out of,
relating to or howsoever attributable to the genetic disorder borne by the insured. The mere fact that the
insured was diagnosed with Gilbert Syndrome cannot be a sufficient reason for denial of the claim.
The insured was admitted for appendicectomy and the procedure was not done due to the unstable
bilirubin levels and the physician was not confident to conduct the surgery without complications. Thus
the complainant is eligible for reimbursement of the claim.
Aggrieved by the denial of the claim, the complainant sent representation to the grievance cell of the
respondent insurer regarding the unfair rejection of the claim. The only repercussion of the diagnosis of
the Gilbert Syndrome has caused is the postponement of the scheduled surgery. It is therefore requested
to his forum that the rightful claim of the patient may be approved and amount relating to the treatment
may be reimbursed.
2. The Respondent Insurer entered appearance and filed a self-contained note. It is submitted that the
Insured Mr. Rajesh P P and his family including his wife and 2 dependent kids are covered under the
Master Policy No. 61-19-00015-00-00 issued to Bajaj Finance Limited against the Company’s product Group
Activ Health. The Insured members are covered under the said policy from 06/02/2020 to 05/02/2021. 2.
The Company was in receipt of Pre-Authorization request for admission of Insured’s son (Master Abhinand
P R) for undergoing treatment of Acute Appendicitis with symptoms of Abdominal pain, vomiting, etc. at
Medical Trust Hospital, Ernakulum from 19/08/2020 to 22/08/2020. A copy of the pre- auth registration
form and is enclosed herewith 3. During perusal of the claims documents submitted, it was revealed that
the Patient was diagnosed with Acute Appendicitis and Gilbert Syndrome. During the current
hospitalisation the treatment for Appendectomy was postponed due to the IVF injection provided and high
level of S. Bilirubin during the course of hospitalisation. The copy of the Discharge Summary is enclosed
herewith 4. It may be taken into consideration that the Company is willing to reconsider the claim
pertaining to the treatment undergone for Appendicitis. The condition of Gilbert syndrome is a genetic
disorder and also falls under waiting period of 48 months as per the Policy terms and conditions. Gilbert’s
syndrome is an inherited liver condition in which the liver cannot fully process a compound called bilirubin.
The Company would request the Insured to submit a Claim reimbursement form with supporting
documents for the Company to consider the claim. 6. In view of the above, we request the Hon’ble
Ombudsman office to close the complaint and allow the Company to adjudicate/settle the claim. However,
we give our consent to Hon’ble Ombudsman to intervene /mediate in the matter if deemed fit.
3. I heard the Complainant and the Respondent Insurer. The Complainant submitted that even though the
cashless was approved, the respondent insurer rejected the claim at the time of discharge from the
hospital. The reason for denial that the patient was having Gilbert syndrome is not right. The reason for
appendicitis is not the genetic disorder and that the claim is payable. The Respondent Insurer submitted
that the denial of cashless is claim is not the final rejection. The medical information as received during
preauthorization was not sufficient to decide whether the claim is admissible and hence the same was
denied. But the complainant didn’t submit original claim form and other medical reports for
reimbursement. If the complainant submits the claim reimbursement forms with supporting documents,
the respondent insurer is ready to consider the claim subject to terms and conditions of the policy.
4. On hearing the complainant and the respondent insurer it is found that the cashless treatment was
denied by the respondent insurer. It is admitted by the complainant that he has not submitted the claim
form for reimbursement. The respondent insurer submitted that the cashless was denied for want of more
details of the ailment whereas the hospital had provided only limited details of the ailment. It is also
submitted that on production of claim form for reimbursement the claim will be considered. The
complainant submitted all the relevant documents and the respondent insurer informed this forum that
out of claimed amount of Rs.26966/-, after deducting Rs. 551/- towards Non payable amount, the
admissible amount is Rs.26415/-.
In the result, an award is passed, directing the Respondent Insurer to pay an amount of Rs. 26415/-, within
the period mentioned hereunder. No cost.
As prescribed in Rule 17(6) of Insurance Ombudsman Rules, 2017, the Insurer shall comply with the award
within 30 days of receipt of the award and intimate compliance of the same to the Ombudsman.
Dated this the 29
th
day of January 2021.
Sd/-
(POONAM BODRA)
INSURANCE OMBUDSMAN
AWARD NO.IO/KOC/A/HI/0388/2020-2021
PROCEEDINGS OF
THE INSURANCE OMBUDSMAN, KOCHI
(UNDER RULE NO. 13 1(i) READ WITH RULE 14 OF
THE INSURANCE OMBUDSMAN RULES, 2017)
Complaint No. KOC-H-005-2021-0646
PRESENT: Ms. POONAM BODRA
INSURANCE OMBUDSMAN, KOCHI.
AWARD PASSED ON 29.01.2021
1.
Name and Address of the complainant
:
Mr. Saju S
TC5/2092,Kuttiyottu Veedu, Cheruvickal,
Sreekaryam P.O, Trivandrum 17
2.
Policy Number
:
canara a/c 2608101003565
3.
Name of the Insured
:
Mr. Saju S
4.
Name of the Insurer
:
Bajaj Allianz General Insc Co. Ltd.,
5.
Date of receipt of Complaint
:
08.12.2020
6.
Nature of complaint
:
Non issue of policy details.
7.
Amount of relief sought
:
--
8.
Date of hearing
:
18.01.2021
9.
Parties present at the hearing
f. For the Complainant
:
Mr. Saju S (online)
g. For the Insurer
:
Ms. Smeeita Salve (online)
AWARD
This is a complaint filed under Rule 13 1(i) read along with Rule 14 of the Insurance Ombudsman Rules,
2017. The complaint is regarding non issue of policy details.. The complainant, Mr. Saju S is the
policyholder.
1. Averments in the complaint are as follows:
The Complainant submitted that he is a customer of Canara Bank, Ulloor branch with account
No.2608101003565. He previously had Group Meidclaim with Appolo Munich Health Insurance through
the Bank till 19.05.2020.When he approached the bank to renew the existing Group mediclaim insurance
through the Bank before 19.05.2020, Bank asked him to renew the Group mediclaim insurance with their
new partner in Group mediclaim insurance, the Bajaj Alliance Insurance Company. He trusted the Bank and
renewed the Group mediclaim insurance with the respondent insurer. He entrusted the annual premium
amount of Rs.7167/- per person for his parents and in-laws. He is the only son for his parents. On
19.05.2020 Bank debited an amount of Rs.21501/- and on 21.05.2020Bank debited an amount of Rs.7167/-
for parents and in-laws of him. Mr.Sivasankaran Nair and Vimalakumari Amma are his parents and
Mr. Krishnan Nair and Mrs Girijakumari are in-laws. As per the Bank statement, Bank debited Rs.28,668/-
from his account with the Bank.
Even after entrusting the premium amount to the respondent insurer, through the Bank for the purpose of
the Health Insurance, the insurance certificate or payment receipt was not provided by them. It is
submitted that the complainant contacted the Bank and the respondent insurer several times over phone
and later visited the Bank and the insurance company offices several times. He never expected such an act
from the side of the a Bank and the insurer even after debiting the amount form the Bank.
On 24.08.2020, three months after paying the amount to the insurer, the complainant had to take his
mother to hospital due to severe health issue. As he lives away from Trivandrum medical college, he took
his mother to Ananthapuri Hospital and Research Centre to get cashless treatment. It is a network hospital
and cashless treatment is available for his mother. On 24.08.2020 he called and informed the respondent
insurer and the Bank. At the highly emotional moments also, both the Bank and the insurer didn’t show
any kind of sympathy. Due to purposeful negligence and breach of trust from the side of the respondent
insurer, she didn’t get cashless treatment at the hospital. The insurer didn’t give the certificate of insurance
and due to the same he couldn’t submit it to the hospital and he was forced to pay the amount for
treatment. It entirely ruined the purpose of paying the premium amount for health insurance. The mala
fide act of the insurer put the complainant in a situation to avail loans from his friends and family at an
emergency situation. To buy medicines from pharmacy outside, he had to resort to loan from IDBI bank by
pledging gold.
On 31.08.2020 at 2.30pm his mother expired, while under treatment at the hospital. He had to provide the
balance bill of Rs.4,12,557/- from the loan amount which gave him huge mental agony and hassle. On the
same day the insurer provided him the health insurance certificate through Whatsapp, but they were not
ready to help him by contacting him or the hospital authority to release the body of his mother, even
though it was a network hospital. After a lot of request from his side the insurer paid Rs.3,77,508/- to the
hospital and the hospital authority refunded the amount to his bank account on 07/09/2020. But this
didn’t help him for the mental agony and financial crisis he went through during the death of his mother
due the mala fide act of the insurer. On 30.09.2020, he had submitted an application for reimbursement of
the outside pharmacy bill for Rs.1,60,990/-to the respondent insurer. So far they didn’t pay the amount. Till
this date the insurer didn’t issue the Health insurance certificate of Mr. Sivashankaran Nair (father) and
Mr.Krishnan Nair( Father in law) to him. He is still requesting for the certificate and the insurer purposefully
not providing it. Hence the complainant prays to this forum to initiate strict legal action against the insurer
and the Bank and award him a reasonable compensation for the mala fide act, deficiency in service and
breach of trust. Also necessary action may be taken to get the insurance certificate of his father and father
in law and the reimbursement amount of Rs.1,60,990/- at the earliest.
2. The Respondent Insurer entered appearance and filed a self-contained note. It is submitted that
all averments in the complaint except those that are specifically admitted or dealt with hereunder
are denied by the respondent. There is no deficiency of service or unfair trade practice on the part
of the Insurance Company. Hence the Complaint is liable to be dismissed at the outset for want of
cause of action.
That the averments made in the complaint that insurance company is not ready to pay outside
pharmacy bill and is not purposefully provide health insurance certificate is fully denied. It is
submitted that replying insurance company have issued policies for Mrs. Girija B vide Policy no.
OG-21-1601-6021-00000527) and for Mr. Krishnan Nair B vide policy no. OG-21-1601-6021-
00000813 while policy of Mr. Sivasankaran has not been issued as his medical reports are
pending. This insurance company will issue the policy in the name of Mr. Sivasankaran on
receiving medical reports. This answering insurance company has acted bonafide and has issued
policies, thus there is no deficiency in service on the part of insurance company and therefore,
this petition is liable to be dismissed.
That on receiving claim intimation from the complainant for hospitalization of his mother Vimala
Kumari, insurance company has scrutinized claim documents and accordingly paid the claim
amount to the complainant as per terms and conditions of the insurance policy. This insurance
company had also paid pharmacy charges of amount of Rs. 152857 vide UTR No.
SIN00043Q9819998 dated 30-12-2020. It is denied that replying insurance company had denied
paying pharmacy bill of Rs. 160990 to the complainant. The amount of Rs. 8133 has been
deducted from the bills submitted by the complainant while rest amount has been approved and
the claim has been duly paid to the complainant. It is to be noted that patient has submitted bill of
Rs. 3500 which has different patient thus the said amount has been deducted. Complainant is
trying to gain unjust enrichment by submitting bill of a different patient. As this insurance
company has duly discharged its obligation and has paid the amount to the complainant, thus this
insurance company is not further liable to pay any amount to the complainant.
The respondent is not guilty of any deficiency in service as alleged in the complaint. That, this
Opposite Party humbly begs to reserve its right of amendment of the present Self-contained note
on revelation of new facts and circumstances for facilitating justice in the present case.
3. I heard the Complainant and the Respondent Insurer. The Complainant submitted that he was having
health insurance policy for his parents and for his in laws with Appolo Munich and during 2020 when he
approached for renewal of the p[policies, the Bank authorities asked him to renew the insurance with their
new partner in Group mediclaim insurance, the Bajaj Alliance Insurance Company. Even after debiting the
premium amount from his Bank account, the respondent insurer didn’t issue the Health insurance
certificate. Meanwhile his mother got admitted in the hospital and the cashless treatment was denied by
the respondent insurer. Later he had to bear the hospital expenses from his own pocket. After various
communications, the respondent insurer paid Rs.3,77,508/- to the hospital and the hospital authority
refunded the amount to his bank account. He is yet to receive Rs. 1,60,990/-. Even though the respondent
insurer says that they have approved the amount, the Bank authorities are not giving the amount for want
of some documents. The insurance policy certificate for his father Mr. Sivashankaran Nair is not provided
by the Respondent Insurer. The respondent insurer submitted that they have not denied paying pharmacy
bill of Rs. 1,60,990 to the complainant. The amount of Rs. 8133 has been deducted from the bills submitted
by the complainant while rest amount has been approved and the claim has been duly paid to the
complainant. The insurance certificate of the complainant’s father is not issued. The same will be issued on
receiving required medical reports of Mr. Sivasankaran Nair.
4. The complainant failed to maintain decorum by appearing bare chested in the Online Hearing. This
shows disregard by the complainant to a forum like Ombudsman. Only after instruction by the
Ombudsman, he appeared in formal clothing.
I heard the complainant and the respondent insurer. On scrutiny of the documents it is found that the
respondent insurer has paid Rs.3,77,508/- to the hospital and the balance pharmacy bill was also paid
after deduction of Rs.8133/- to the Bank account. The allegation of the complainant is that the Bank
authorities are not releasing the amount asking for documents from his father. For that issue this forum is
not competent to issue orders. The complainant has to approach Banking Ombudsman. The insurance
certificate of his father is pending for want of medical reports. As the insured is a senior citizen of 75 years
of age, the respondent insurer requires medical reports to renew the policy. The policy with continuity
benefits will be issued on receipt of medical reports if found satisfactory and acceptable since, the issuing
of the policy is based on guidelines put forth by the respondent insurer.
In the result, an award is passed, directing the Respondent Insurer to renew the policy with continuity
benefits subject to production of satisfactory medical reports by the complainant and respondent insurer’s
underwriting guidelines, within the period mentioned hereunder. No cost.
As prescribed in Rule 17(6) of Insurance Ombudsman Rules, 2017, the Insurer shall comply with the award
within 30 days of receipt of the award and intimate compliance of the same to the Ombudsman.
Dated this the 29
th
day of January 2021.
Sd/-
(POONAM BODRA)
INSURANCE OMBUDSMAN
AWARD NO. IO/KOC/A/HI/0390/2020-2021
PROCEEDINGS OF
THE INSURANCE OMBUDSMAN, KOCHI
(UNDER RULE NO. 13 1(b) READ WITH RULE 14 OF
THE INSURANCE OMBUDSMAN RULES, 2017)
Complaint No. KOC-H-049-2021-0580
PRESENT: Ms. POONAM BODRA
INSURANCE OMBUDSMAN, KOCHI.
AWARD PASSED ON 29.01.2021
1.
Name and Address of the complainant
:
Mrs. Sini C T
Aswathy, Nellikkodu, Vadasserikkonam
P O , Varkala, Trivandrum 695143
2.
Policy Number
:
120700/34/19/04/00000008-CHE
3.
Name of the Insured
:
Mr. Sidharth
4.
Name of the Insurer
:
The New India Assurance Co. Ltd.
5.
Date of receipt of Complaint
:
04.12.2020
6.
Nature of complaint
:
Rejection of mediclaim
7.
Amount of relief sought
:
--
8.
Date of hearing
:
9.
Parties present at the hearing
f. For the Complainant
:
Claim already settled
g. For the Insurer
:
AWARD
This is a complaint filed under Rule 13 1(b) read along with Rule 14 of the Insurance Ombudsman Rules,
2017. The complaint is regarding rejection of mediclaim. The complainant, Mrs. Sini C T is the
policyholder.
1. Averments in the complaint are as follows:
The Complainant stated that she is an LIC officer . She claimed for pre authorization for her son’s
hospitalization for surgery on 13/7/2019 . Her son was discharged on 24/7/19 at 11.50 am and at 7.20 pm
she was informed of approval of Rs.20,000/- but there was no further response , so she decided to pay the
bill and claim reimbursement. Next day she got a denial letter and later she received a letter dt. 20/9/19
with a rejection letter stating that the procedure undergone was a cosmetic/ aesthetic procedure not
arising out of an ailment or injury. Her repeated requests and clarification from doctor, was in vain. She
requests the Ombudsman to inquire and give a reasonable verdict .
2. The Respondent Insurer entered appearance and filed a self contained note. It is submitted that they
have settled the claim for Rs.54,532/-on 2/12/2020.
3. The respondent insurer has settled the claim for Rs.54,532/-on 2/12/2020 and the Complainant has
received the claim amount on 5/12/2020 and being satisfied, has withdrawn the complaint.
In the result, an AWARD is passed for Dismissal of the complaint.
Dated this the 29
th
day of January 2021.
Sd/-
(POONAM BODRA)
INSURANCE OMBUDSMAN
AWARD NO.IO/KOC/A/HI/0392/2020-2021
PROCEEDINGS OF
THE INSURANCE OMBUDSMAN, KOCHI
(UNDER RULE NO. 13 1(b) READ WITH RULE 14 OF
THE INSURANCE OMBUDSMAN RULES, 2017)
Complaint No. KOC-H-051-2021-0546
PRESENT: Ms. POONAM BODRA
INSURANCE OMBUDSMAN, KOCHI.
AWARD PASSED ON 29.01.2021
1.
Name and Address of the complainant
:
Mr. SAJIN P PAUL,
PUTHENVEETTIL HOUSE, THARISH P.O., KANNATH
- 676523; MALAPPURAM
2.
Policy Number
:
500100/28/19/P1/11088846
3.
Name of the Insured
:
Ms. Jaisy Joseph
4.
Name of the Insurer
:
The United India Insurance Co. Ltd.
5.
Date of receipt of Complaint
:
23.11.2020
6.
Nature of complaint
:
Rejection of mediclaim
7.
Amount of relief sought
:
--
8.
Date of hearing
:
08.01.2021
9.
Parties present at the hearing
For the Complainant
:
Mr. Sajin P Paul (online)
For the Insurer
:
Ms. Srijani (online)
AWARD
This is a complaint filed under Rule 13 1(b) read along with Rule 14 of the Insurance Ombudsman Rules,
2017. The complaint is regarding rejection of mediclaim. The complainant, Mr. SAJIN P PAUL is the
policyholder.
1. Averments in the complaint are as follows:
The Complainant stated that his spouse is covered under The South Indian Bank Ltd. .United India
Insurance Co. Ltd., corporate policy. His spouse was admitted in the Kims Al Shifa Hospital,
Perinthalmanna , Kerala, on 22.12.19 with fever, severe cough, head ache & body tiredness. On admission,
she was fixed with IV cannula set and on request with the consulting doctor it was removed and suggested
for oral medications in consideration with the feeding of the baby.S he was discharged on 24.12.19.
Cashless/reimbursement of the claim was rejected (due to the absence of injections, fluids), under policy
clause 4.7 :- charges incurred primarily for diagnosis, x-ray or lab examinations. The sum insured is Rs.4lacs
along with super top up policy having a sum insured of Rs.5lacs. Totally the sum insured is Rs.9Lacs and the
policy period is from 1.10.19 to 30.9.20. The quantum of relief sought is Rs.21,440/-, along with interest
plus interest @Rs.2,000/-, per day.
2. The Respondent Insurer entered appearance and filed a self contained note. It is submitted that a group
Mediclaim policy to South Indian Bank employees : 5001002819P111088846 for period 01-Oct-2019 To
30-Sep-2020. Sajin P Paul along with his child Jaisy Joseph is included by South Indian Bank in the list
of insured persons. Jaisy Joseph was the patient in the claims regarding which the complaint has been
made. The claim details are :
Name & Address of the
Hospital
Kimsalshifa
Date of Admission
22.12.2019
Type of Claim
Reimbursement
Nature of Illness
LRTI
Total Amount Claimed
Rs.21440.00.-
On scrutiny of the claim documents by TPA it was found that the patient was diagnosed with LRTI.
The hospitalization was mainly for diagnosis purpose. Accordingly the claim was repudiated under
the policy exclusion clause 4.7 , which reads as :Charges incurred at Hospital or Nursing Home
primarily for diagnosis x-ray or Laboratory examinations or other diagnostic studies not consistent
with or incidental to the diagnosis and treatment of positive existence of presence of any ailment,
sickness or injury, for which confinement is required at a Hospital . Nursing Home, unless
recommended by the attending doctor.
3. I heard the Complainant and the Respondent Insurer. The Complainant submitted that his spouse was
hospitalised on 22.12.19 with fever, severe cough, head ache & body tiredness and was discharged on
24.12.19. The claim was rejected stating that the charges incurred were primarily for diagnosis, x-ray or
lab examinations. During the hospitalization, the complainant`s spouse was with IV cannula set and on
request was removed and suggested for oral medications in consideration with feeding of her baby. The
Respondent Insurer submitted that on scrutiny of the claim documents by TPA, it was found that the
patient was diagnosed with LRTI. The hospitalization was mainly for diagnosis purpose. Accordingly the
claim was repudiated under the policy exclusion clause 4.7
4. 4.I heard the complainant and the respondent insurer and had gone through the records submitted by
them. The discharge summary indicates that the insured was admitted for the period 22.12.19 to 24.12.19,
with fever associated with cough with yellowish expectoration and headache. Medical tests/ investigations
were conducted to arrive at a proper diagnosis of the illness and treatment. The discharge
summary/doctor`s certificate confirms that the insured was diagnosed and treated for LRTI. Therefore,
hospitalization in this case is justified and evaluation & investigations were required to arrive at a proper
diagnosis of the illness for treating the patient. Hence the respondent insurer is directed to pay the
admissible amount of Rs.18,340/- submitted as detailed below, as per the policy terms & conditions.
Bill
No.
Bill Date
Acc. Head
Days/Nos
Req.
Amt.(Rs)
Rejd.
Amt.(Rs)
Allwd.
Amt.(Rs)
Remarks
719
24/12/2019
Room Rent
2
6000
0
6000
Nursing
2
2400
0
2400
Pharmacy
2095
210
1885
handrub
Registration
100
0
100
consultation
1200
0
1200
Medical and other
charges
1600
1600
0
no details
CT scan
3700
0
3700
Suite kit, bmw
290
290
0
not
payable
Total of Main bill
17385
2100
15285
18
22/12/2019
Laboratory
1820
0
1820
IV canulation
60
0
60
Glucometer strip
60
0
60
Pharmacy
14
0
14
419
19/12/2019
Registration
50
0
50
17
19/12/2019
Pharmacy
57
0
57
14
19/12/2019
Pharmacy
404
0
404
5026
20/12/2019
Laboratory
270
0
270
8659
20/12/2019
Pharmacy
140
0
140
819
19/12/2019
consultation
180
0
180
Total
20440*
2100
18340
Hospital main bill Rs 19,339/-
pre hospitalisation bill Rs 1,101/-
He has submitted only bill amount of Rs 20,440/-
In the result, an award is passed, directing the Respondent Insurer to pay the admissible amount of
Rs.18,340/-, subject to the submission of bills/records and as per the policy terms & conditions, within the
period mentioned hereunder. No cost.
As prescribed in Rule 17(6) of Insurance Ombudsman Rules, 2017, the Insurer shall comply with the award
within 30 days of receipt of the award and intimate compliance of the same to the Ombudsman.
Dated this the 29
th
day of Jan 2021.
Sd/-
(POONAM BODRA)
INSURANCE OMBUDSMAN
AWARD NO.IO/KOC/A/HI/0401/2020-2021
PROCEEDINGS OF
THE INSURANCE OMBUDSMAN, KOCHI
(UNDER RULE NO. 13 1(b) READ WITH RULE 14 OF
THE INSURANCE OMBUDSMAN RULES, 2017)
Complaint No. KOC-H-018-2021-0535
PRESENT: Ms. POONAM BODRA
INSURANCE OMBUDSMAN, KOCHI.
AWARD PASSED ON 29.01.2021
1.
Name and Address of the complainant
:
Mr. Antony Chirayil John,
Chirayil (H),H. No. 1/1806, William P Manuel
Road, Kochi 682001
2.
Policy Number
:
P501643900
3.
Name of the Insured
:
Johaan Antony
4.
Name of the Insurer
:
HDFC ERGO General Insurance Company Ltd.
5.
Date of receipt of Complaint
:
18.11.2020
6.
Nature of complaint
:
Denial of mediclaim
7.
Amount of relief sought
:
--
8.
Date of hearing
:
13.01.2021
9.
Parties present at the hearing
For the Complainant
:
Mr. Antony Chirayil John(online)
For the Insurer
:
Mr. Shivangikar (online)
AWARD
This is a complaint filed under Rule 13 1(b) read along with Rule 14 of the Insurance Ombudsman Rules,
2017. The complaint is regarding denial of mediclaim. The complainant, Mr. Antony Chirayil John is the
policyholder.
1. Averments in the complaint are as follows:
The Complainant submitted that he was holding a Health policy with the respondent insurer ( Earlier
Appolo Munich Health Insurance Company) with policy No P501643900. His son Johaan Antony got
admitted in Medical Trust Hospital due to Pneumonia. The claim lodged for his son was denied by the
respondent insurer stating that the complainant had Scleroderma. While taking the policy he had informed
that he is a diabetic patient. The ailment scleroderma was diagnosed on 21.09.2019 that too after taking
the policy. The complainant has approached this forum for directing the respondent insurer to settle the
health claim of is son.
2. The Respondent Insurer entered appearance and filed a self-contained note. It is submitted that
Mr. Antony Chirayil John (the “Proposer”) submitted duly filled up Enrolment Form bearing
number CB20311543 dated 20-07-2019 (the “Enrolment Form”) proposing the issuance of an
“Group Assurance Health Plan” Policy which has been specially customized for the customers of
CANARA BANK to Apollo Munich Health Insurance Co. Ltd. (“Company”) proposing to insure his
health with sum assured of Rs.1,00,000/-. The Complainant had submitted the Enrolment Form on
behalf of the Complainant after going through the terms and conditions of the policy. The details
of the Policy were also explained to him by the insurance agent/sales representative. It is
pertinent to mention herein that the Complainant had full knowledge of the terms and conditions
of the Policy and only after going through the application for Insurance, thoroughly and properly,
had submitted the Enrolment Form.
That further to above, the Proposer in the declaration paragraph of the Enrolment Form dealing
with “Declaration & Warranty on behalf of all persons proposed to be insured” has agreed and
declared to the following:-
“I/we hereby declare, on my behalf and on behalf of all persons proposed to be insured that the
above statements, answers and/or particulars given by me are true and complete in all respects to
the best of my knowledge”.
That believing the above said declaration, information and details provided including the medical
history by the Proposer in the Enrolment Form to be true, correct and complete in all respect,
giving due credence to the under writing norms of Company, a Policy No. 120100/ 12586/
2019/ A016466/PE01643900 was issued to the Complainant along with his Spouse and 2 sons for
a period commencing from 20-07-2019 till 19-07-2020.
That it is further submitted that the Policy Kit containing all relevant documents along with the
Enrolment Form were duly received by the Proposer thereby giving an opportunity to Proposer to
verify and examine the benefits, terms and conditions of the Policy taken by the Proposer. It is
pertinent to submit that the Complainant/Proposer never approached the Company stating that
any information given in the documents in the Policy Kit was incorrect or any term and condition
therein is not understandable or acceptable to her within from the receipt of the Policy
document. As no objection was received from the Complainant, therefore the Complainant is
strictly bound by the terms and conditions of the policy.
That it is submitted that during the continuation of the Policy period, the Complainant
approached the Answering Respondent to avail Cashless Facility Request vide Cashless Claim ID:
680633 for the hospitalization of the Insured namely Johaan Antony on 02-11-2019 at Medical
Trust Hospital. The Insured herein was diagnosed with Dengue Fever.
It is submitted that the Answering Respondent had also raised query in Complainant’s Claim
(claim id : 662564 ). After receipt of the present cashless claim, the Answering Respondent
Company sent its query letter dated 04-11-2019 and requested the Complainant to provide
following documents:-
1)Kindly send admission notes in case sheet, detail treatment chart/vitals chart/ temp chart
2) kindly confirm exact diagnosis with supporting investigation reports. 3)kindly provide discharge
summary and HPE/BIOPSY REPORT OF SCERODERMA/lichen planus of - Antony Chirayil John
That in the Query Reply, the Complainant sent its Discharge Summary dated 01-10-2019 , from
perusal of the Discharge Summary it was noted that the Complainant had past history of
symptoms of scleroderma since 6 years along with hyper pigmented lesion on B/L lower limb
since 1 years i.e Prior to the Policy inception.
The relevant portion of the Discharge Summary is attached herewith for your kind perusal:-
That in the light of the above noted non-disclosure the claim of the Insured was rejected and the
same was intimated to the Complainant vide letter dated 12-11-2019.
That post rejection the above mentioned Cashless claim, the Complainant filed Reimbursement
Claim vide Claim ID: 1370180 for an amount of Rs.151805/- for the above mentioned
hospitalization of the of the Insured namely Mr. Johaan Antony from 02-11-2019 till 20-11-2019 at
Medical Trust Hospital. The Complainant herein was diagnosed with Dengue Fever Pneumonia.
In the light of the above noted observation made during the Cashless claim and Reimbursement Claim, the
Claim of the Complainant was rejected under non-disclosure of material information i.e Past history of
scleroderma and fatty liver since 1 year i.e. prior to policy inception and the same was intimated to the
Complainant vide letter dated 10-10-2020.
That in the light of the above noted non-disclosure of Past history of scleroderma since 6 years
and fatty liver since 1 year i.e. prior to policy inception, the Answering Respondent also
terminated the Policy of the Complainant and the same was intimated to the Complainant vide its
letter dated 04-03-2020. Also the Answering Respondent refunded Rs.6,157/- towards the
unexpired Policy period.
That it is further submitted that if the Proposer would have disclosed about Complainant’s Past
history of scleroderma since 6 years and fatty liver since 1 year i.e. prior to policy inception at the
time of policy inception, then the Answering Respondent would not have issued the above
mentioned Policy to the Complainant.
That further it is pertinent to mention here that the claims are paid by any Insurance Company
out of the common pool of funds belonging to all Proposers of the Company which makes it
obligatory upon the Insurance Company to check the admissibility of each claim in strict sense of
the Policy Terms and Conditions before honoring the same in the larger interest of all the Policy
Holders. It is further submitted that Complainant’s policy has been cancelled for the concealment
of a grave material fact of his past medical history of Past history of scleroderma since 6 years
and fatty liver since 1 year i.e. prior to policy inception, hence neither the policy can neither be
reinstated nor the Complainant could be given any other benefit.
3. I heard the Complainant and the Respondent Insurer. The Complainant submitted that he had
lodged a claim under the health insurance policy with the respondent insurer for his son’s
hospitalization. The respondent insurer repudiated the claim stating that the complainant had
suppressed a material fact that he was suffering from scleroderma. The complainant submits that
the ailment was diagnosed only on 29.09.2019 that too after taking the policy. He has lodged the
claim for his son’s hospitalization. Denying the claim stating that father has an ailment is not fair.
The Respondent Insurer submitted that the complainant had given wrong declaration in the
Enrolment Form while proposing for the insurance. If the Proposer would have disclosed about
his Past history of scleroderma since 6 years and fatty liver since 1 year i.e. prior to policy
inception at the time of policy inception, then the Answering Respondent would not have issued
the above mentioned Policy to the Complainant.
4. On hearing both the parties and on scrutiny of the documents, it is found that the complainant
has filled in the Enrolment Form and signed the “Declaration & Warranty on behalf of all persons
proposed to be insured” has agreed and declared - “I/we hereby declare, on my behalf and on
behalf of all persons proposed to be insured that the above statements, answers and/or
particulars given by me are true and complete in all respects to the best of my knowledge”. On
believing the declaration, the respondent insurer had issued the policy. But later they have found
that the declaration is wrong and for concealment of a material fact the claim was repudiated .
The policy got cancelled and the premium for the unexpired period was refunded by the
respondent insurer. The decision was taken by the insurer as per terms and conditions of the
policy. Hence I do not want to interfere in to the decision of the respondent insurer to repudiate
the claim and cancel the policy.
In the result, an AWARD is passed for Dismissal of the complaint.
Dated this the 29
th
day of January 2021.
Sd/-
(POONAM BODRA)
INSURANCE OMBUDSMAN