The Hyderabad III District Consumer Redressal Forum has directed a public sector insurance company to release a claim amount of Rs 3 lakh and also pay Rs 25, 000 as compensation to a customer for unjustified rejection of claim.
C Sahadeva Rao had a stent implanted in Chennai’s Fortis Malar Hospital after being diagnosed with a ‘Single Vessel Disease’ and discharged on Sept 23, 2014. But Rao’s claim of cashless treatment as well as reimbursement was rejected by Oriental Insurance Company on grounds of ‘pre-existing nature of illness’. Rao, who had a valid policy, denied being treated for hypertension or diabetes prior to inception of policy.
The insurer also contended that the treatment could have been given on an outpatient basis, pleading for dismissal of the case. But during trial the bench dismissed the company’s contention that a procedure such as placing a stent could be conducted on an outpatient basis.
The bench further said: “A person suffering from silent diseases such as hypertension and diabetes may not even be aware of it until condition aggravates. In the absence of cogent evidence we are of the view that repudiation of claim is unjust, illegal and clearly the opposite parties were deficient in service in repudiating cashless hospitalisation.”
In the end, the bench fined the insurer and also ordered a payment Rs 3,000 towards cost of filing the complaint.
The bench dismissed the company’s contention that placing a stent could be conducted on an outpatient basis