New Delhi:
A consumer forum here has asked insurance companies not to reject claims on "whimsical and technical grounds" as people buy mediclaims to cover medical exigencies.
"Consumers purchase mediclaim policies to cover medical emergencies and exigencies and the insurance company should not reject claims on whimsical and technical grounds," the North Delhi District Consumer Disputes Redressal Forum said.
The forum, headed by its President K S Mohi, directed the Oriental Insurance Co Ltd to pay Rs 90,879 along with a sum of Rs 10,000, to Saket resident Keshav Saran Sharma, holding that the company had rejected his claims on frivolous grounds.
It rejected the company's claim that the patient's insurance cover had expired and held that there was no delay in renewal of the policy.
"In this case, there is not even a single hour break in the 2nd policy. Therefore, taking into view the totality of facts and circumstances of the case and especially the fact that the patient was discharged on January 30, 2012 i.e. well within the currency of the insurance policy, the repudiation by the insurance company was illegal and unjustified," it said.
In his complaint, Sharma had said he taken a mediclaim policy valid from January 27, 2011, till midnight of January 26, 2012, and the sum insured was Rs 2,50,000.
He said that his wife was admitted for treatment of breast cancer on January 26, 2012 at Max Super Specialty Hospital in Saket and discharged within four days.
Sharma had also claimed that the premium for renewal of policy was paid on January 23, 2012 but the insurance company renewed the policy by maintaining the continuity from 00.00 hours January 27, 2012 till midnight of January 26, 2013.
The insurance company rejected the claim of Sharma saying that the patient was admitted on January 26, 2012, which was the date of expiry of the policy.
The forum observed that the company had collected the premium cheque dated January 23, 2012, much before the date of policy renewal.
"This policy also shows that the premium cheque dated January 23, 2012 for a sum of Rs 23,514 was collected by the company on Januanry 23, 2012 i.e. much before the date of renewal of the policy," it held.
