A consumer disputes redressal forum has directed Life Insurance Corporation of India to pay Rs5.30 lakh (besides penal interest) to a family from Ghatkopar whose claim had been dishonoured. The legal tangle between the family of the insured person and the insurance firm centred around what constitutes an ‘accident’.
The son of the insured person, Devji Patel, had made a claim for the policy amount after the insured person died in 2005. According to the ‘double accident benefit’ policies Patel had taken, his family was to receive Rs 5.30lakh after his death provided his death was caused by an accident.
Patel died on July 10, 2005 – four days after falling on the staircase of the building in which he lived and sustained head injuries. Patel, who had a blood pressure problem, died of cardiac arrest.
The Patels put up a claim to the insurance firm for the ‘double accident benefit’. While the family expected to be paid Rs5.30 lakh, the firm approved a payment of half the amount — Rs2.15 lakh.
When Kiran questioned the firm about the amount, the company claimed that Patel’s death could not be considered ‘accidental’ and so the ‘accident benefit’ would not accrue in this case. The firm’s contention was that Patel, who had blood pressure problem, died a natural death and the family could claim the accident benefit.
That’s when Patel’s son, Kiran, approached the consumer forum to lodge a complaint against Life Insurance Corporation. The insurance firm claimed that the family’s claim was “false, frivolous and not based on facts”. The insurance firm also stated that Patel had had a ‘natural death’, not an accidental one.
After considering the medical evidence of Patel’s death besides other proof that Kiran had submitted, the Mumbai Suburban district (Additional) consumer dispute redressal forum ruled that Life Insurance Corporation was ‘guilty of providing deficient service to its consumer’. Besides Rs5.30lakh, the forum has asked the firm to pay 10 per cent interest per annum from November 2006.
No pre-packages for ailments
The General Insurance Council, an umbrella body of about 30 insurance firms, on Thursday told the high court of its inability to come up with pre-packaged compensation for 42 ailments based on amount assured and type of hospital. The court had asked the council to work out guidelines for a pre-packaged scheme
“Insurance companies are not equipped to or in a position to advise or determine packages or uniform rates for medical treatment. Hospitals are strangers to insurance contracts and, hence, they are not obliged to accept the rate specified by insurance companies,” the affidavit stated
The court directive followed a public interest litigation on hardship of mediclaim policyholders
The court has given the council another three weeks to find out a via media to introduce
pre-packages
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