Insurance company ordered to compensate policy holder for non-payment of claim

The consumer alleged deficiency in service by the company as he was compelled to pay Rs 11,300 towards charges of medication and treatment due to denial of cashless facility by the company.

The National Insurance Company has been penalized by the UT Consumer Disputes Redressal Forum here for denying a cashless policy to a consumer for a medical treatment.

Rakesh Jaspal, a resident of Sector 39, stated in his complaint that he took out a medi-claim policy from the company in January 2011, by paying a premium of Rs 9,495 as premium.

A couple of days later, Jaspal, the complainant, fell ill and was admitted at the Fortis Hospital at Mohali where at the time of admission, he provided a copy of the cashless policy. During the treatment the hospital sought confirmation from Vipul Medicorp T P A Limited, a health facilitation company, about the cashless policy, which it denied.

Rakesh alleged deficiency in service by the company for the fact that he was compelled to pay Rs 11,300 towards charges of medication and treatment due to denial of cashless facility by the company. In its written reply, the insurance company submitted that merely obtaining cashless insurance policy did not mean that every claim would be paid to the insured.

They pleaded that according to the policy, it was a second renewal by the insurer and that coronary disease would be covered only after four continuous claim free years.

On examining the record, the forum observed that the policy was first taken by the complainant in 2005 and that the claim of the insurance company of it not been in continuation was rendered unjustified. Further, it observed that the complainant need not submit any bills as it was a cashless policy and the expense be paid directly to the hospital.

... contd.

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