2 hrs ago
Haryana commission orders insurer to pay full US treatment claim
A 73-year-old woman became seriously ill while visiting the United States.
She had travel insurance worth up to 100,000 US dollars.
She had told the insurer that she had diabetes before buying the policy.
In Texas, she suffered heart failure and needed an angioplasty.
Her hospital bill was much higher than the amount the insurer initially paid.
The insurer paid only 9,900 dollars because it said her diabetes helped cause the heart problem.
A consumer commission said the insurer had accepted the diabetes when it issued the policy.
It ordered the company to pay another 90,000 dollars.
The commission also ordered compensation for the trouble and legal costs she faced.
A Haryana consumer commission ordered the insurer to pay USD 90,000, about Rs 85 lakh, to a 73-year-old woman.
The woman had purchased USD 100,000 travel insurance for a 61-day trip to the United States after disclosing her diabetes.
She was hospitalized in Texas on March 19, 2022, for acute heart failure and NSTEMI and underwent angioplasty.
The insurer paid only USD 9,900, arguing that diabetes contributed to her cardiac condition and limited coverage to 10 percent.
The commission also awarded Rs 1.22 lakh for mental agony, harassment and litigation costs, finding the denial arbitrary and unfair.
- Who
- A 73-year-old woman, her travel insurer, and the Haryana District Consumer Commission.
- What
- The commission ordered the insurer to pay USD 90,000 plus Rs 1.22 lakh after it restricted a heart-treatment claim to USD 9,900.
- Where
- The treatment occurred in Texas, United States, and the consumer case was heard in Haryana.
- When
- The woman was hospitalized on March 19, 2022; the commission’s order was issued on August 25, with the year not stated.
- Why
- The commission found that the insurer could not use the woman’s disclosed and accepted diabetes to reduce coverage without clear policy language.
Consumer Commission and Policyholder
Insurance Company
Effect of disclosed diabetes
Consumer Commission and Policyholder
The commission held that the insurer had accepted and priced the disclosed diabetes when issuing the policy, so it could not later use that condition to arbitrarily reduce the claim.
Insurance Company
The insurer argued that the woman’s diabetes was linked to her cardiac condition and that the policy allowed only 10 percent of the sum insured for treatment related to a pre-existing disease or its complications.
Meaning of the policy terms
Consumer Commission and Policyholder
The commission said the insurer had not clearly established that its provision for a life-threatening condition due to a pre-existing disease capped the primary inpatient-care benefit at 10 percent; ambiguities should favor the insured.
Insurance Company
The insurer maintained that the claim had already been settled according to the policy’s terms and conditions and challenged the maintainability of the consumer complaint.
Claim handling
Consumer Commission and Policyholder
The commission found the denial of the remaining claim to be a deficiency in service and an unfair trade practice, noting that the family had to arrange money urgently in a foreign country.
Insurance Company
The insurer paid USD 9,900 and maintained that this payment complied with the applicable coverage restriction.
Key facts
- Policy coverage
- USD 100,000 single-trip international travel insurance
- Premium
- Rs 30,494
- Travel period
- March 1 to April 30, 2022
- Initial insurer payment
- USD 9,900, or 10 percent of the sum insured
- Hospital bill
- USD 145,838
- Commission’s award
- USD 90,000 plus Rs 1.22 lakh for mental agony, harassment and litigation costs
- Medical treatment
- Acute heart failure, NSTEMI and angioplasty
Quotes
Haryana District Consumer Commission
Consumer commission adjudicating the woman’s insurance complaint
“Nowadays, it has become a trend for insurance companies to issue the policies by giving false assurances, and when the insured amount is claimed, they make such type of excuses. Thus, the denial of the claim of the complainant is arbitrary and unjustified.”
indianexpress.com
“The act of the opposite party, while declining the remaining claim amount, amounts to deficiency in services and unfair trade practice, which is otherwise proved genuine.”
indianexpress.com
Sources
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