Chandigarh: Forum directs insurance firm, third party company to furnish Rs 48,000 for not paying full medical claim

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The SBI said in its reply that the expenses rejected under the claim were not mentioned in the issuance of the policy or its breach by the Paramount Service Insurance TPA Private and SBI General Insurance. (Representational Image)

The Consumer Forum of Chandigarh directed an insurance firm and its third party company to pay Rs 48,000 to an elderly man for not paying him the full amount of the medical claim.

The complainant, 61-year-old Charanjit Singh of Chandigarh alleged that he had become a member of the Health Policy of SBI General Insurance and he fell ill on December 9, 2017, and remained admitted as an in-patient at Healing Hospital in Sector 34 of Chandigarh. He was discharged on December 13, 2017. Singh said that a bill of Rs 79,354 was raised by the hospital, for which he made the payment and later submitted the same to the insurance firm, However, the firm refunded an amount of Rs 41,947 and the remaining amount of the claim was rejected on the grounds that it was not covered under the policy. Singh, thus, moved the forum and filed a formal complaint on September 27, 2018.

The SBI said in its reply that the expenses rejected under the claim were not mentioned in the issuance of the policy or its breach by the Paramount Service Insurance TPA Private and SBI General Insurance. The firm was proceeded against ex-parte.

The Paramount Service Insurance TPA Private Limited, despite having been served notice, allowed itself to be proceeded against ex-parte, while SBI General Insurance company filed its separate written reply and said, whatever amount was admissible under the policy was refunded to the complainant and the remaining amount was not reimbursed as it fell in exclusion clause.

The forum, after hearing the arguments, held that it was admitted that the complainant remained admitted as an in-patient and whatever medicines and other articles were purchased by him and the bill paid to the hospital was on the recommendation of the doctor. The medicines and the other articles purchased as per prescription were required for the restoration of his health. The forum said, there was hardly any justification to repudiate the remaining claim which pertained to the investigation charges, registration charges of the hospital and the other medicines, along with the rent of the private ward and thus, they were needed to be reimbursed in totality.

The forum ordered the Paramount Service Insurance and SBI General Insurance company to pay the remaining claim of Rs 33,826 to the complainant, alongwith an interest at 9 per cent per annum from March 16, 2018 till the amount’s realisation. It also ordered the firms to pay Rs 10,000 as compensation and Rs 5,000 as cost of litigation.