The District Consumer Disputes Redressal Forum in Jalandhar has pulled up an insurance company for rejecting the mediclaim of a heart patient and ordered it to pay Rs 1.64 lakh along with compensation and litigation costs.
Case Background
The complainant, a resident of Jalandhar, had taken a mediclaim policy from the insurance firm. He was diagnosed with a heart ailment and underwent angioplasty at a hospital. Upon discharge, he filed a claim for the medical expenses incurred. However, the insurance company rejected the claim, citing a pre-existing disease clause and alleging non-disclosure of medical history.
Consumer Forum's Observation
The forum examined the policy terms and medical records. It noted that the patient had not concealed any material facts. The insurance company failed to prove that the ailment was pre-existing or that the policyholder had misrepresented his health condition. The forum observed that the rejection was arbitrary and amounted to deficiency in service.
Order and Compensation
The forum directed the insurer to pay Rs 1.64 lakh as the claim amount, along with interest at 9% per annum from the date of rejection until payment. Additionally, the company was ordered to pay Rs 10,000 as compensation for mental agony and Rs 5,000 as litigation costs. The order must be complied with within 45 days.
Implications for Policyholders
This ruling reinforces the rights of policyholders and emphasizes that insurers cannot reject claims arbitrarily. Consumers are advised to maintain transparency while purchasing policies and to retain all medical records. In case of unjust rejection, they can approach consumer forums for redressal.
The decision serves as a reminder to insurance companies to adhere to ethical practices and process claims in a fair manner.
