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Risk firm told to pay consumer for rejecting mediclaim

Wednesday, 21 May 2014 - 6:50am IST | Agency: dna

The Mumbai suburban districts additional consumer forum on Tuesday held Royal Sundaram Alliance Insurance guilty of providing faulty services to a consumer. The firm repudiated the complainant's mediclaim policy claim amount citing her illness to be a "chronic one".

The forum has ordered the firm to pay the claim amount of Rs91,000 along with 10% interest from January 2010. The forum has also asked the firm to pay Rs15,000 for causing the complainant mental agony and Rs3,000 for her litigation cost.

The case dates back to July 2006, when Jyoti Mehta had approached a city-based bank for a vehicle loan. The bank officials told her to purchase a mediclaim policy first. She bought a policy of Royal Sundaram Alliance insurance firm, which provided her with medical cover of up to Rs1.15 lakh and was active between July 2006 and July 2007. The complainant regularly paid the premium of Rs2,839 and also continued with the policy for 2009-10 and regularly renewed it.

According to the forum's order copy, the complainant, on June 23, 2009, suffered some breathing problem because of which she was hospitalised.

"The complainant claimed that apart from other expenses, her total hospital bills came up to Rs80,000. After she was discharged from the hospital, her relatives approached the firm and submitted the bills, seeking reimbursement," claimed the complainant.

However, the firm repudiated the bills on the ground that the complainant was hospitalised as she had some problem in her lungs, an ailment she was suffering from for a long time, even before she bought the policy, and, hence, as per the policy's clauses, the claim cannot be honored.

The complainant approached the forum and registered a complaint. The forum then asked the firm to file its reply. The firm maintained its reasons.

The forum held that the ground on which the firm repudiated the claim was that it won't reimburse consumers suffering from chronic illness; however, as per a doctor's definition, a six-month-old ailment can also be termed chronic. "Repudiating the mediclaim only on the use of the word chronic was wrong," held the forum.

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