Mumbai: Terming rejection of medical claim for not meeting the demand of providing clarification on an affidavit from the treating doctor as “unreasonable and arbitrary”, the District Consumer Disputes Redressal Commission (Central Mumbai) has directed the insurance firm to process the claim with interest.
The insurance firm had rejected the claim after not getting the clarification on an affidavit, even though the doctor had provided it on his letterhead. The Commission directed that the claim of Rs68,527 be given with 9% interest from the date of filing the complaint till its realisation. The Commission also directed payment of Rs22,500 for mental agony and litigation cost.
The order dated Jan 8, 2023 was passed by Commission president SS Mhare and member MP Kasar on a complaint from Parel resident Narayan Pawar against Apollo Munich Health Insurance Co. Ltd.
Mr Pawar took a Rs3 lakh medical policy with Rs60,000 cash back before being detected with diabetes. He also paid a premium of Rs13,815 before he was admitted to hospital from Sept 27 to Oct 10, 2018. For treatment, he asked for reimbursement of Rs68,527.
However, the firm rejected the claim saying that the affidavit of the doctor was not provided. Mr Pawar then filed a complaint with the Commission, alleging deficiency in service and unfair trade practice. During the hearing, the hospital didn’t appear or file any written statement, so an ex-parte order was passed and the allegations against it remained unchallenged.
The insurance firm sought additional documents and an affidavit from the treating doctor for clarification of discrepancy in exact duration of diabetes and hypertension. The doctor, in turn, informed Mr Pawar that such information is given on letterhead and if the insurance firm still wants an affidavit, then it should contact the hospital.
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The Commission observed that the insurance firm failed to give an answer as to why it required details on affidavit despite being on the doctor’s letterhead. Stating that the reasons for rejection were not as per terms and conditions of the policy, it directed that the claim be given within 30 days of the order because there was deficiency in service.
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