1 hr ago
Chhattisgarh Commission Orders Insurer to Pay Heart Claim
A man had health insurance and needed expensive heart treatment.
His family asked the insurance company to reimburse the medical bills.
The company refused because the family had not provided the original documents.
The family said it had provided certified copies and could show the originals for checking.
A consumer commission in Raipur said the insurer should not reject the claims only for that reason.
It ordered payment of Rs 12.75 lakh within the limits of the two policies.
It also awarded Rs 1 lakh for mental suffering and Rs 10,000 for legal costs.
The case shows that insurance payments are still limited by the policy’s coverage amount.
The Raipur District Consumer Commission ordered a private insurer to pay Rs 12.75 lakh under two health policies.
It also awarded Rs 1 lakh for mental harassment and Rs 10,000 in litigation costs.
The family’s claims followed the man’s treatment at hospitals in Delhi, Hyderabad and Chennai in 2015.
The insurer rejected the claims, saying the family had not submitted original medical documents despite reminders.
The commission ruled that certified or notarised copies could not be disregarded when originals remained available for verification.
- Who
- The deceased man’s wife and two sons brought the complaint against a private insurance company.
- What
- The Raipur District Consumer Commission ordered the insurer to pay Rs 12.75 lakh in covered claims, plus compensation and litigation costs.
- Where
- The case was decided by the District Consumer Commission in Raipur, Chhattisgarh; treatment took place in Delhi, Hyderabad and Chennai.
- When
- The treatment occurred in March-July 2015; the complaint was filed in 2016, and the commission issued its order on September 21.
- Why
- The commission found that rejecting the claims solely because original documents were not submitted amounted to deficiency in service and an unfair trade practice.
Family and Consumer Commission
Insurance Company
Missing original documents
Family and Consumer Commission
The family said it had submitted notarised or certified copies and was willing to produce the originals for verification; the commission held that the claims could not be rejected solely for this reason.
Insurance Company
The insurer said the required original documents were not provided despite repeated reminders and therefore rejected the claims.
Amount payable
Family and Consumer Commission
The family sought reimbursement of eligible medical expenses, while the commission awarded amounts limited to the coverage under each policy.
Insurance Company
The insurer disputed liability over the documentation issue; the commission did not allow claims above the insured limits.
Key facts
- Claim award
- Rs 12.75 lakh under the 2014-15 and 2015-16 policies
- Additional compensation
- Rs 1 lakh for mental harassment
- Litigation expenses
- Rs 10,000
- 2014-15 coverage
- Rs 6.25 lakh, including a Rs 1.25 lakh bonus
- 2015-16 coverage
- Rs 6.50 lakh, including a Rs 1.50 lakh recharge benefit
- Insurance history
- The deceased had been covered under the family plan continuously since 2010
- Treatment expenses
- Rs 4.22 lakh at AIIMS Delhi, Rs 6.83 lakh at Care Hospital, Hyderabad, and Rs 12.04 lakh at Fortis Hospital, Chennai
Quotes
Raipur District Consumer Commission
Consumer commission bench that decided the insurance dispute
“As per the insurance policy for the year 2015–16 submitted in the record, the sum insured under the ‘samayojan’ provision is Rs 5 lakh, while the recharge benefit is Rs 1.50 lakh. Therefore, instead of the amount of Rs 12.04 lakh claimed by the complainant under the 2015–16 insurance policy, it would be appropriate to award the total insured amount of Rs 6.50 lakh, along with interest.”
indianexpress.com
“The courts, including the national commission and the state commission, have held that it is not proper to dismiss a claim merely due to the absence of documents. Dismissing a claim solely because the original documents were not produced is contrary to law and amounts to deficiency in service and an unfair trade practice.”
indianexpress.com
Sources
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