Insurance Co directed to compensate for denying medical claim

A District Consumer Disputes Redressal Forum here has directed an insurance company to compensate a woman for denying her mediclaim of Rs 64,705, observing that the rejection was unwarranted and devoid of merit.
"When the treatment is undertaken by the unfortunate insured, the insurance company takes a somersault and immediately takes up the terms and conditions of the policy which admittedly were not supplied to the insured at the time of inception of the policy," the forum observed while awarding Rs 8,000 compensation to north Delhi resident Vandana Dalmia.
"The insured feels cheated at the hands of insurance company," the forum headed by President K S Mohi said.

"The insured seldom gets the terms and conditions at the time of inception of the policy or any subsequent thereto. But the insurance companies, in order to evade their liability, press into service their terms and conditions when the claim is filed," the forum, also comprising members Subhash Gupta and Shahina, observed.
"We are of the considered view that the repudiation of claim of the insured by the insurance company were wholly unwarranted and devoid of any merit and therefore, it constituted deficiency in service," it said.
It also directed the award of Rs 64,705 with interest at the rate of 6 per cent from the date institution of the complaint till payment, besides another Rs 8,000 towards harassment mental agony loss of time and litigation cost.

According to the complaint, Dalmia was admitted to a hospital for liver-related (Lap Cholecystectomy) treatment on February 7, 2011 which cost her Rs 64,705.

However, the medical claim towards her hospitalisation and treatment was rejected by Oriental Insurance Company Ltd, saying as per the terms and conditions of the policy taken by Dalmia, the disease suffered by her could not be covered in the first year of the policy.
Dalmia further alleged that the insurance company while issuing the policy had never apprised her about any such condition and had not even supplied the policy with alleged conditions and clauses as they were claiming.

The insurance company claimed that as per terms and conditions of the policy, they were not liable for any claim and prayed for the dismissal of the complaint.
"The insurance company has miserably failed to establish as to by which mode (it had) supplied the terms and conditions to the insured. The law is now well settled which lays down that the insurance company cannot take shelter under the umbrella of terms and conditions unless the same were duly furnished to the insured," the forum observed.