Insurance firm directed to pay Rs 30k medical claim

Tribune News Service

Amritsar, November 10

The District Consumer Dispute Redressal Forum has directed an insurance company to pay Rs10,485 deducted from the medical insurance claim of a local resident.

Ramesh Chaudhary, a local resident, had filed a complainant against the National Insurance Company stating that he purchased a medical insurance from the company and fell ill during its validity. He said he spent an amount of Rs30,485 for eye treatment that he underwent at a local hospital. Even as he was insured for a sum of Rs8 lakh, he had to pay the hospital bill from his own pocket. He alleged that later, the insurer paid Rs20,000 and withheld Rs10,485, despite his repeated demands.

The company, in its reply, stated that the amount had been deducted as a part of various terms and conditions set in the policy. The forum observed that the only plea of the company in deducting the said amount was that the deductions had been made according to the terms and conditions of the policy. It said, however, that the case of the complainant was that he was provided only the cover note and policy terms and conditions were not conveyed to the complainant. The forum stated that the company could not produce any document to prove that the terms and conditions were supplied to the insured.

It further said even in terms and conditions, it was mentioned that upto 10 per cent of sum insured or actual, whichever is lower, was guaranteed. In the present case, that amount came out to be Rs80,000 (10 per cent of 8 lakh). It said the incurred sum was less than Rs80,000 and so, the complainant was entitled to payment of full amount, that is, Rs 30,485.