Insurance Ombudsman

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, GUWAHATI

(UNDER RULE NO: 16(1)/17 of INSURANCE OMBUDSMAN RULES 2017) OMBUDSMAN – K.B. SAHA

CASE OF: : Complainant MR BEDABIT ACHARYA VS THE ORIENTAL INSURANCE CO. LTD. COMPLAINT REF NO: GUW – H-50-2021-0140: Award No:

1. Name & Address of the Complainant

MR BEDABIT ACHARYA REHABARI BILPAR, HOUSE NO.26,GUWAHATI -781008.

2. Policy No: Type of Policy Duration of policy/Policy period

321105/48/2021/349 ,SI Rs 4,00,000/--, Group Mediclaim Tailor made Policy . 1 Year /From 13.07.2020 to 12.07.2021.

3. Name of the insured Name of the policyholder

MR BEDABIT ACHARYA RASHTRIYA GRAMIN VIKASH NIDHI.

4. Name of the insurer THE ORIENTAL INSURANCE CO. LTD.

5. Date OF OCCURANCE OF LOSS/CLAIM

20.10.2020

6. DETAILS OF LOSS The Insured was covered by the Group Mediclaim policy for the period from 13.07.2020 to 12.07.2021. He was admitted to Swagat Super Speciality Surgical Institute, Guwahati on 20.10.2020. He was diagnosed with Calculus Cholecystitis .His Laparoscopic Cholecystectomy was done at hospital on 21.10.2020. Insured lodged a claim of Rs 1,58,055/-to the Insurer.

7. REASON FOR GRIEVANCES Insurer settled his claim bill at Rs 88,332/- on 04.12.2020. Insured was not satisfied with the settlement amount and hence, put up his grievance at this Forum.

8.a 8.b

Nature of complaint Date of receipt of the complain

Unsatisfied over his settlement amount. 01.02.2021

9. Amount of Claim Rs 47,500/=. 10. Date & Amount of Partial

Settlement Rs 88,332/- on 04.12.2020.

11 Amount of relief sought Rs 47,500/=

12. Complaint registered under Rules of Ins Ombudsman 2017

13(1)(b)

13. Date of hearing/place 26.02.2020 at O/O Ins Ombudsman Office, Guwahati. 14. Representation at the hearing For the Complainant Mr Bedabit Acharya For the insurer Mr Ranabir Ganguli.

15 Complaint how disposed Through personal hearing and online hearing 16 Date of Award/Order 10.03.2021

17) Brief Facts of the Case: The Insured was admitted to Swagat Speciality Surgical Institute, Guwahati on 20.10.2020 and diagnosed with Calculus Cholecystitis. The doctors performed Laparoscopic Cholecystectomy on 21.20.2020.He was discharged from the Hospital on 24.10.2020. The Insured lodged a claim of Rs 1,58,055/-to the Insurer. The Insurer settled his claim bill at Rs 88,332/- on 04.12.2020. Insured was not satisfied with the settlement of claim and made complaint at this Forum settlement of his balance amount of claim.

18 (a) Complainant’s argument: The Insured stated that Insurer settled his claim bill at Rs 88,332/- on 04.12.2020, which was approx 55% of the total bill. The Insured was not satisfied with the settlement amount. The Insured had alleged that his claim for Rs 2500/- for Covid -19 test , Hospital charge for Rs 5200/- and consumables charge Rs 39,800 for Trocker i.e. total for Rs 47,500/-was illegally deducted by the company. Hence, he had put up his grievance at this Forum for natural justice. 18 (b) Insurers’ argument: The Insurer stated that a renewal Group Mediclaim Tilormade policy bearing no. 321102/48/2021/349 was issued to M/s Rashtriya Gramin Vikash Nidhi covering their employees for the period from 13.07.2020 to 12.07.2021 and the Insured – patient was also covered by the policy. The Insured lodged a claim for Rs 1,58,055/- against which Rs 88,322/- was paid for full and final settlement of the claim. The Insurer stated the Investigation charge related to Covid test for Rs 5200/- is not payable as it is not related to the treatment of the disease. The bed charge amounting Rs 4000/- and nursing charges Rs 1200/- i.e. total Rs 5200/-, is related to Recovery room. A recovery room is a room near the operating or delivery room of a hospital ,used for recovery from anesthesia of a postoperative or obstetrical patient before taking them to a hospital room or ward. The bed charges and the OT charges as levied by the hospital has been paid to the claimant. The recovery room being a part of the Operation Theater, has been already charged in the bill amounting to Rs 8000/- as ‘Operation Theater Charge’ . The equipment used in the treatment of Laparoscopic gallbladder removal surgery has been levied in the bill under procedure charge as Equipment amounting to Rs 10,000/-which is already paid. Trocar and LASER Fiber are tools for easy access in minimal invasive surgeries and are reusable after sterilization. As per the bill , the trocker device has been treated under OT Consumable and not as instrument during operation procedure of gall bladder . Hence, the amount is not admissible. 19) Reason for Registration of Complaint: - Scope of the Insurance Ombudsman Rules 2017 (Rule after proper approval from honorable ombudsman13 (1) (b). 20) The following documents were placed for perusal. a) Complaint letter b) Annexure – VI A c) Copy o the policy d) Annexure VII A e) S C N Result of hearing with both parties (Observations & Conclusion):- Both the parties were called for hearing on 26 .02.2021. The complainant Mr. Bedabit Acharya was present and the insurer was represented by Mr Ranabir Ganguly. DECISION We have taken in to consideration the facts and circumstances of the case from the documentary as well as verbal submission made by the claimant as well as representative of the Insurance company. On perusal of claim papers, policy documents and arguments of Insured and Insurer, it is noted that the Insured was admitted to the hospital for Calculus Cholecystitis and Lacparoscopic Cholecystectomy was done in the hospital. The Insured complained with the Forum against deduction of bill for Covid -19 Rs 2500/- , Recover charge Rs 5200/ and Consumable for Troker Rs39,800/- i.e. total for Rs 47,500/- made by Insurer while processing the claim. It is noted as per the documentary evidence and verbal submission of the Insured and the Insurer’s representative present in the hearing that the Covid -19 test was not related with treated disease, so it is not payable. Only the hospital services was incurred by patient after operation i.e. discharged from OT for recovery, which is a integral part of treatment and is to be treated as applicable room rent. On the other hand, the Consumable charge for Troker i.e. instrument is not payable as per the policy terms and conditions. The trocker device is treated under OT Consumable and not as instrument during operation procedure. Insurer also sent some documents confirming trocker as reusable system through mail on 02/03/2021. Billing of reusable trocker system as OT consumable is surely an unethical practice by the hospital. However, the Insurance Company is not liable to reimburse the same as part of the claim. The complainant may approach an appropriate court of law for resolution of his grievance.

Under the circumstances and in order to ensure fairness to the policy holder, the claim is hereby awarded to be paid by the insurer as under for full and final settlement of the claim: Hospital service charge against Recovery room for 1 day = Rs 4,000/- TOTAL PAYABLE AMOUNT(In addition to earlier payments) = Rs 4,000/- Hence, the complaint is treated as closed. The attention of the Complainant and the Insurer is hereby invited to the following provisions of Insurance Ombudsman Rules, 2017. As per Rule 17(6) of the said rules the Insurer shall comply with the Award within 30 days of the receipt of the Award and intimate the compliance of the same to the Ombudsman. Dated at- Guwahati 10th March. 2021. K.B.Saha INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, GUWAHATI (UNDER RULE NO: 16(1)/17 of INSURANCE OMBUDSMAN RULES 2017)

OMBUDSMAN – K.B. SAHA CASE OF: : Complainant MR. AVERIL R.J.NONGBET VS UNIVERSAL SOMPO GENERAL INSURANCE CO.LTD

COMPLAINT REF. NO: GUW-G-052-2021-0073: Award No

1. Name & Address of the Complainant MR.AVERIL R.J.NONGBET

2. Policy No:

Type of Policy

Duration of policy/Policy period

3333/59685445/00/000

PERSONAL ACCIDENT POLICY

13/06/2018 TO 13/04/2019,S.I.Rs.10,00000/-

3. Name of the insured

Name of the policyholder

LARRY KUPAR JANA KUPER NONGBET LARRY KUPAR JANA KUPER NONGBET

4. Name of the insurer UNIVERSAL SOMPO GENERAL INSURANCE CO.LTD.

5. Date OF OCCURANCE OF LOSS/CLAIM 30/05/2019

6. DETAILS OF LOSS Rs.1000000/-(S.I.)

7. REASON FOR GRIEVANCES Rules 17(6) of the Insurance ombudsman Rule 2017

8.a

8.b

Nature of complaint

Date of receipt of the complain

REPUDIATION OF THE CLAIM

23/02/2021

9. Amount of Claim AS PER ENTITLEMENT

10. Date & Amount of Partial Settlement NIL

11 Amount of relief sought AS PER ENTITLEMENT

12. Complaint registered under Rules of Insurance Ombudsman 2017

13(1)(b)

13. Date of hearing/place O/o Insurance Ombudsman Guwahati

29/03/2021

14. Representation at the hearing

For the Complainant MR.AVERIL R.J.NONGBET

For the insurer MR.PROSHANT V SHUKLA

15 Complaint how disposed Through personal Hearing

16 Date of Award/Order 29/03/2021

17) Brief Facts of the Case: As stated by the complainant Mr. Averil R.J.Nongbet that his brother (late) Larry Kupar Jana

Nongbet had enrolled for IOB Suraksha (Group Personal Accident Insurance Scheme) on 13/06/2018. Complainant is the

nominee of the policy. On 30/05/2019 at around 21.50 hrs to 22.00 hrs Larry Kuper met with a fatal hit at Shillong Jowai road

near Assam Auto Agency Petrol Pump, Fire Brigade, Shillong and had died on spot. Death Certificate was issued on

28/06/2019 and accordingly Mr. Nongbet had filed the claim with all the documents required.After a long gap & harassment,

on 19/08/2020 he was asked to receive an unsigned rejection letter addressed to the Bank dated 05/06/2019 from Universal

Sompo General Insurance Co. Ltd . The rejection was made under policy clause of requirement of post mortem report. As the

complainant submitted the Post Mortem Exempted Certificate signed by Additional District Magistrate, Khasi Hills, he is not

satisfied with the reason of repudiation of the claim. So he approached us for reconsideration of the claim.

18 a) Complainant’s Argument: - Complainant submitted the approval of exemption of Post Mortem by Additional District

Magistrate of East Khasi Hills District,Shillong dated 31/05/2019. The approval was forwarded by In-Charge Laitumakhrah

Traffic Branch,East Khasi Hills,Shillong against the prayer for exemption from post mortem of the dead body of LA by

complainant.In the forwarding I/C TRAFFIC Branch written that ‘during enquiry it is learnt that the case is purely an accident

case and there is no any foul play found.’

After repeated enquiries at IOB Shillong on 19/08/2020 he was asked to receive an unsigned rejection letter dated

05/06/2019 from insurer that was addressed to IOB. As cause of rejection was non submission of post mortem report the

complainant submitted a request for reconsideration of his claim along with IOB Suraksha Claim Process details which states

Post Mortem Report is not mandatory.

He also stated that the policy number of his brother late Larry Kuper Jana Nongbet mentioned as per this unsigned claimed

Rejection letter is policy no.3333/59685445/00/000 did not tally with the Master policy number in the enrollment form

which is 333/58241289/00/000.

He had also raised his objection to the fact that the IOB, Shillong Branch/Universal that he was made aware of this fact after

a passage of 1 year through the letter of rejection issued by Universal Sompo General Insurance Co. Ltd.

He also stated that the policy number of his brother late Larry Kuper Jana Nongbet mentioned as per this unsigned claimed

Rejection letter is policy no.3333/59685445/00/000 did not tally with the Master policy number in the enrollment form

which is 333/58241289/00/000.

18b) Insurers’ argument: Insurance co. submitted the following points in their SCN-:

1. The plain reading of Group Personal Accident policy terms and conditions clearly spells out “We undertake

that in the event of ‘Accidental’ Bodily injury sustained by the insured person(s) during the policy period, we will

make payment to them or their legal representative/nominee as per the Table of Benefits set forth in the policy

provided that all the terms, conditions and exceptions of this policy in so far as they relate to anything to be

done or complied with by them have been met.

2. After scrutinizing the documents placed in the claim file and after due application of the mind by the officials

of the insurance company, the claim of the complainant was repudiated vide letter dated 05/06/2020 on the

ground of non-submission of post mortem report by the nominee claiming under the policy. Insurance co.

clarified it further that as stated in the complaint that the unsigned letter was sent, the reason for which is that

the nation was reeling under nationwide lockdown and Maharastra (Mumbai) was the worst hit state and they

were prevented to come to their office getting signatures, stamped and scanning. However, Insurance co. had

also informed the IOB vide their email dated August 18, 2020 regarding rejection of the claim of the insured.

3. Insurance co. further stated in their SCN that, following documents shall be required in the event of a

claim(the same has been envisaged under terms and conditions of Group Personel Accident policy.)

For death claim

Duly filled up claim form

Death certificate

Original FIR original panchnama

Post mortem report

4.The concern of the complainant with regard to policy number is changed is that the product under which the

complainant is claiming is a group personal accident & the policy number gets changed every year as the

beneficiaries are added and deleted every year. Hence the policy number gets changed every year.

5. As regards the issue of non-payment of claim under the policy, Insurance co. affirm their stand yet again and

stated that when the post mortem report is not made available to them, their right to verify the fact with regard

to the admissibility of a claim got prejudiced. It is understood that the cause of death along with the

ascertainment of any intoxication/drug abuse cannot be ruled out in absence of a vital and inevitable document

viz-a viz post mortem report for the purpose of analysis of the claim.

6. Insurance co. submitted it further that Group Personal Accident Policy has Death and Disablement benefits.

However, as far as IOB Suraksha Scheme for this group is concerned the policy has been underwritten for

Accidental Deaths only’ for the beneficiaries of the policy.

7. The concern of the Complainant that the word ‘if applicable’ has been mentioned on IOB website is untenable

as a Post Mortem will not be conducted in cases of Disablement. Hence, requirement of Post Mortem will not

arise in case of Disablement.

8.As the complainant is seeking clarification as to why the post mortem exemption accorded under the seal and

signature of a government official namely the Additional District Magistrate East Khasi Hills stating “No foul

play is suspected’ is not a reason for exemption of Post Mortem Report. We would like to submit that the best

known reason for exemption of a post mortem is best known to the applicant making an application to Deputy

Commissioner which has nothing to do with Insurance perspective. The purpose of injury report and Inquest

Report are very much different from the Post Mortem Report. The Insurance is a contract between Insured and

Insurer only; the Insurer has every right to get the claim verified and conditions fulfilled before accepting any

liability. In cases of Death more importantly an accidental death a Post Mortem Report plays a very vital

position in deciding the admissibility of any claim. The insurers right to verify the claim gets prejudiced in

absence of the necessary documents.

19) Reason for Registration of Complaint: -: Scope of the Insurance Ombudsman Rules 2017 (Rule after proper

approval from honorable ombudsman13 (1) (b).

20) The following documents were placed for perusal. a) Complaint letter b) Annexure – VI A c) Copy o the policy d) Annexure VII A e) S C N

Result of hearing with both parties (Observations & Conclusion):- Both the parties were called for hearing on 29/03/2021. The complainant was represented by Mr.Averil R.J. Nongbet himself and the insurer was represented by Mr. PROSHANT V SHUKLA.

DECISION

We have taken into consideration the facts & circumstances of the case from the documentary as well as

verbal submission made by the claimant and representative of Insurance co. We have also gone through the

records.

Insurance co.repudiated the claim on the ground of non-submission of Post Mortem Report. But

complainant submitted the approval of exemption of Post Mortem by Additional District Magistrate of

Khasi Hills District,Shillong dated 31/05/2019.The approval was forwarded by In-charge Laitumukhrah

Traffic Branch,East Khasi Hills,Shillong against the prayer for exemption from post mortem of the dead body

of LA by complainant.In the forwarding letter I/C Traffic Branch had written that ‘during enquiry it is learnt

that the case is purely an accident case and there is no any foul play found’. Moreover,in course of hearing

the complainant clarified that the reason for seeking exemption was basically emotional and religious

consideration.

It is clear from the Investigation report of In-Charge Laitumukhrah Traffic Branch,East Khasi Hills,Shillong

that it is a pure accidental case. Claimant also submitted the sketch map of Accident Site and GR Case

No.115(s) of 2019 of Chief Judicial Magistrate,Shillong of the accident.So,it is clear that,the cause of death

of L/A is accident and as per i.c.,Traffic there was no foul play involved.

During the course of hearing Insurance co. also stated that the cause of death along with the ascertainment

of any intoxication/drug abuse cannot be ruled out in absence of a very vital and inevitable document viz

Post Mortem Report for the purpose of analysis of the claim. But they could not produce any proof or

document against their claim.There was no such indication in the investigation report of police also.So,this

point is ignored.

During the course of hearing Insurance co. also had mentioned a point that the claimant submitted the

claim intimation after one month of the incidence. But in his letter claimant alleged that,he submitted the

claim in time and was again harassed by Bank and Insurer before finally accepting the claim documents.It is

also very illogical to question the time frame of claim process as it was a very sad demise.

The exemption of post mortem was approved by state Govt. Officer of the rank of Additional District

Magistrate of East Khasi Hills District,Shillong dated 31/05/2019.The approval was forwarded by In-Charge

Laitumakhrah Traffic Branch,East Khasi Hills,Shillong against the prayer for exemption from post mortem of

the dead body of LA by complainant.In the forwarding I/C Traffic Branch had clearly written that ‘during

enquiry it is learnt that the case is purely an accident case and there is no any foul play found.’It shows that

full official protocol was maintained and it is expected that competent authority has given due deliberations

before approving the exemption of post mortem. The Insurer’s decision is prejudiced with baseless

suspicion and they have taken recourse of purely untenable legalese without any due diligence and

application of mind.

Under the above circumstances & in order to ensure fairness to the insured this forum is in the opinion that

insurance co. had wrongly repudiated the claim & directs the insurance co. to pay full sum insured of

Rs.1000000/- to the nominee of the insured as final settlement of the claim.

Hence the complaint is treated as closed.

The attention of the Complainant and the Insurer is hereby invited to the following provisions of Insurance

Ombudsman Rule 2017.

As per Rule 17(6) of the said rules the Insurer shall comply with the Award within 30 days of the receipt of

the award and shall intimate the compliance of the same to the Ombudsman.

Dated at Guwahati, the 29th Day Of March , 2021

K.B.Saha

Insurance Ombudsman

PROCEEDINGS BEFORE - THE INSURANCE OMBUDSMAN, STATE OF M.P. & C.G. (UNDER RULE NO: 16(1)/17 OF THE INSURANCE OMBUDSMAN RULE 2017)

OMBUDSMAN – G S SHRIVASTAVA Mr. K.C.Jain …..……..……………………………..……………….……….….Complainant

V/s United India Insurance Co. Ltd. ………....….………….…….……...…………...Respondent

COMPLAINT NO: BHP-H-051-2021-0260 ORDER NO: IO/BHP/A/HI/0085/2020-2021

Mr K.C.Jain (Complainant) has filed a complaint against United India Insurance Co. Ltd.(Respondent) alleging rejection of claim of child (Amira Jain) of his daughter-in-law.


Mr. K.C.Jain 1, Avantika Parisar, Lalghati Bhopal


021002819P100272169 Group Mediclaim Policy for New India Insurance Co. Ltd 01.04.2019 to 31.03.2020


Mr. K.C.Jain- Claim of Amira Jain New India Insurance Co Ltd

4. Name of the insurer United India Insurance Co. Ltd

5. Date of Repudiation/ Rejection 27.10.2020

6. Reason for Repudiation/ Rejection Dependent / Daughter-in-law is not covered under the Policy since 3 years

7. Date of receipt of the Complaint 02.03.2021

8. Nature of complaint Rejection of claim

9. Amount of Claim Rs.1,68,693/-

10. Date of Partial Settlement --

11. Amount of relief sought Rs.1,68,693/-

12. Complaint registered under Rule Rule No. 13(1)(b) Ins. Ombudsman Rule 2017

13. Date of hearing/place On 18.03.2021 at Bhopal


For the Complainant Mr K C Jain over Go To Meeting App

For the insurer Ms Shikha Malviya, Administrative Officer, over Go To Meeting App

15. Complaint how disposed Dismissed

16. Date of Award/Order 18.03.2021

Brief facts of the Case –

Contention of the complainant - The Complainant has stated that the claim was repudiated by TPA on 27.10.2020 stating therein as ‘Maternity benefit extended to an independent child or a family member of the dependent / independent child, provided such child or family member has been covered in the policy for 3 years as on date of hospitalization under the maternity cover. But the said dependent / daughter in law is not covered in the policy since 3 years only so claim of new born is also not admissible hence the claim recommended for rejection under the clause 1.2A(f). In this connection he added that his daughter in law gave birth to twins and the same were covered by paying additional premium of Rs.5,148/- covering the risk from Sept.2019 to March 2020. As per clause no. 2.6 sub Clause (h) ( Maternity Expenses and New born Child Cover) it is clearly mentioned that the new born child shall be covered from the day one upto the age of 3 months and expenses incurred for treatment taken in hospital as in patient shall only be payable subject to the full sum insured. He has stated further that initially TPA approved the claim on SMS on 08.10.2020 which respondent repudiated on 27.10.2020.

Contention of respondent- The respondent in their SCN have stated that Mrs.Payal Jain daughter in law of complainant was hospitalized for treatment of SGA/LSCS/IVF/MALE/VLBW/RDS (birth of child) from 18.09.2019 to 10.10.2019. The insured lodged a claim under the said Group Health Policy and Health claim was repudiated for breach of clause no 1.2A (f) of the policy and revised guidelines of Group Medical policy for employees and retirees of GIPSA and as per circular dated 06.03.2017. The clause states that ‘Maternity benefit extended to an independent child or a family member of dependent / independent child provided such child or family member has been covered in the policy at least for 3 years as on date of the hospitalization under maternity cover’. It is further stated that Payal Jain (daughter in law) covered in the policy since 2017 only. Maternity benefit extended to an independent child or a family member of dependent / independent child provided such child or family member has been covered in the policy atleast for 3 years as on date of hospitalization under the maternity cover. But the said dependent / Daughter in law is the not covered in the policy since 3 years only hence claim rejection was done under the clause 1.2 A (f).

The Complainant has filed complaint letter, Annex. VIA and correspondence with respondent while respondent have filed SCN with enclosures.

I have heard both parties over Go To Meeting App at length and perused paper filed on behalf of the complainant as well as the Insurance Company.

Observation and Conclusion : A claim under above policy was lodged by the complainant for the reimbursement of expenses incurred in the treatment of Amira Jain, second baby of his daughter in law, Payal Jain from 18.09.2019 to 10.10.2019 which was repudiated by the respondent under clause 1.2(A)(f) stating maternity benefit is extended only when the dependent (here it refers to Daughter in law) is covered under the policy since 3 years as on date of hospitalisation. Policy clause No.1.2(A)(f) provides that maternity benefit shall be extended to an independent child or a family member of dependent / independent child provided such child or family member has been covered in the policy at least for the last 3 years as on date of the hospitalization under maternity cover. It is admitted fact that daughter in law of the complainant was not covered under the policy for the past three years and was covered only since 2017. Complainant has referred to clause No.2.6 (h) of the policy and has stated that new born child shall be covered from the day one upto the age of 3 months and expenses incurred for treatment taken in hospital as in patient shall only be payable subject to the full sum insured, hence claim is payable. Representative of the respondent opposed the above argument and stated that in this case as the 3 years continuous coverage of mother of new born child was not completed, hence the provision of clause 1.2 (f) shall apply. As the continuous coverage of mother of

the child has not completed three years, hence the rejection of the claim under clause 1.2(f) of policy by respondent is in order. Clause 2.6(h) referred by complainant also pertains to maternity expenses and newborn child cover benefit extension. It is pertinent to mention here that as maternity expenses itself is not covered under 1.2(f) then the question of applicability of clause 2.6(h) does not arise. Complainant in his complaint has stated that the twins delivered by his daughter in law were covered under the policy as he had paid premium of Rs.5,148/- covering their risk from September, 2019 to March 2020 and submitted a receipt dated 04.10.2019. On perusal of receipt dated 04.10.2019 it is seen that the receipt does not specify as to whom, since when and for what coverage / policy, the receipt was issued. Even policy number and date of commencement is not specified on the receipt. Supporting document such as Certificate of Insurance has also not been provided by the complainant. Hence with this receipt it cannot be inferred that the new born child was covered or not (on the date of hospitalisation of the patient for whom claim was filed). Hence the repudiation by respondent is as per policy and needs no interference by this forum. In the result, compliant is liable to be dismissed.

Let copies of the order be given to both the parties. Dated : Mar 18, 2021 (G.S.Shrivastava) Place : Bhopal Insurance Ombudsman

OMBUDSMAN – G S SHRIVASTAVA

Mr. K.C.Jain…..…….……………………..……………….…………….…..….….Complainant V/s

United India Insurance Co. Ltd. ………....….………….…….……...…………...Respondent

COMPLAINT NO: BHP-H-051-2021-0262 ORDER NO: IO/BHP/A/HI/0086/2020-2021

AWARD

The complaint filed by Mr K C Jain stands dismissed herewith.


Mr. K.C.Jain 1, Avantika Parisar, Lalghati Bhopal


021002819P100272169 Group Mediclaim policy for New India Insurance Co.Ltd 01.04.2019 to 31.03.2020


Mr. K.C.Jain- Claim of Mr. Amay Jain New India Insurance Co.Ltd.

4. Name of the insurer United India Insurance Co. Ltd

5. Date of Repudiation/ Rejection 27.10.2020

6. Reason for Repudiation/ Rejection Dependent / Daughter-in-law is not covered under the Policy since 3 yeras


8. Nature of complaint Rejection of claim


Mr K.C.Jain (Complainant) has filed a complaint against United India Insurance Co. Ltd.(Respondent) alleging repudiation of claim of child (Amay Jain) of his daughter-in-law.

Brief facts of the Case – a) Contention of the complainant - The Complainant has stated that the claim was repudiated by TPA on 27.10.2020 stating therein as ‘Maternity benefit extended to an independent child or a family member of the dependent / independent child, provided such child or family member has been covered in the policy for 3 years as on date of hospitalization under the maternity cover. But the said dependent / daughter in law is not covered in the policy since 3 years only so claim of new born is also not admissible hence the claim recommended for rejection under the clause of 1.2A(f). In this connection he added that his daughter in law gave birth to twins and the same were covered by paying additional premium of Rs.5,148/- on dated 04.10.2019 for covering the risk from Sept.2019 to March 2020. As per clause no. 2.6 sub Clause (h)( Maternity Expenses and New born Child Cover) it is clearly mentioned that the new born child shall be covered from the day one upto the age of 3 months and expenses incurred for treatment taken in hospital as in patient shall only be payable subject to the full sum insured. He stated, further, that initially TPA approved the claim on SMS on 08.10.20 which respondent repudiated on 27.10.2020.

Contention of respondent- The respondent in their SCN have stated that Mrs Payal Jain daughter-in-law of Insured was hospitalized for treatment of SGA/LSCS/IVF/MALE/VLBW/RDS (birth of child) from 18.09.2019 to 10.10.2019. The insured lodged a claim under the said Group Health Policy and Health Claim was repudiated for breach of clause no 1.2A (f) of the policy and revised guidelines of Group Medical policy for employees and retirees of GIPSA and as per circular dated 06.03.2017. The clause states that ‘Maternity benefit extended to an independent child or a family member of dependent / independent child provided such child or family member has been covered in the policy at least for 3 years as on date of date of the hospitalization under maternity cover’. It is further stated that Payal Jain (daughter in law) covered in the policy since 2017 only. Maternity benefit extended to an independent child or a family member of dependent / independent child has been covered in the policy after 3 years as on date of hospitalization under the maternity cover. But the said dependent / Daughter in law is the not covered in the policy since since 3 years only. Hence claim rejection was done under the clause 1.2 A (f).

The Complainant has filed complaint letter, Annex. VIA and correspondence with respondent while respondent have filed SCN with enclosures.

I have heard both parties over Go To Meeting App at length and perused paper filed on behalf of the complainant as well as the Insurance Company.

Observation and Conclusion : A claim under above policy was lodged by the complainant for the reimbursement of expenses incurred in the treatment of Amay Jain, first baby of his daughter in law, Payal Jain from 18.09.2019 to 10.10.2019 which was



12. Complaint registered under Rule Rule No. 13(1)(b) Ins. Ombudsman Rule 2017

13. Date of hearing/place On 18.03.2021 at Bhopal


For the Complainant Mr K C Jain over Go To Meeting App

For the insurer Ms Shikha Malviya, Administrative Officer over Go To Meeting App



repudiated by the respondent under clause 1.2(A)(f) stating maternity benefit is extended only when the dependent (here it refers to Daughter in law) is covered under the policy since 3 years as on date of hospitalisation. Policy clause No.1.2(A)(f) provides that maternity benefit shall be extended to an independent child or a family member of dependent / independent child provided such child or family member has been covered in the policy at least for the last 3 years as on date of the hospitalization under maternity cover. It is admitted fact that daughter in law of the complainant was not covered under the policy for the past three years and was covered only since 2017. Complainant has referred to clause No.2.6 (h) of the policy and has stated that new born child shall be covered from the day one upto the age of 3 months and expenses incurred for treatment taken in hospital as in patient shall only be payable subject to the full sum insured, hence claim is payable. Representative of the respondent opposed the above argument and stated that in this case as the 3 years continuous coverage of mother of new born child was not completed, hence the provision of clause 1.2 (f) shall apply. As the continuous coverage of mother of the child has not completed three years, hence the rejection of the claim under clause 1.2(f) of policy by respondent is in order. Clause 2.6(h) referred by complainant also pertains to maternity expenses and newborn child cover benefit extension. It is pertinent to mention here that as maternity expenses itself is not covered under 1.2(f) then the question of applicability of clause 2.6(h) does not arise. Complainant in his complaint has stated that the twins delivered by his daughter in law were covered under the policy as he had paid premium of Rs.5,148/- covering their risk from September, 2019 to March 2020 and submitted a receipt dated 04.10.2019. On perusal of receipt dated 04.10.2019 it is seen that the receipt does not specify as to whom, since when and for what coverage / policy, the receipt was issued. Even policy number and date of commencement is not specified on the receipt. Supporting document such as Certificate of Insurance has also not been provided by the complainant. Hence with this receipt it cannot be inferred that the new born child was covered or not (on the date of hospitalisation of the patient for whom claim was filed). Hence the repudiation by respondent is as per policy and needs no interference by this forum. In the result, compliant is liable to be dismissed.

Let copies of the order be given to both the parties. Dated : Mar 18, 2021 (G.S.Shrivastava) Place : Bhopal Insurance Ombudsman

AWARD

The complaint filed by Mr K C Jain stands dismissed herewith.

PROCEEDINGS BEFORETHE INSURANCE OMBUDSMAN, CHANDIGARH (UNDER INSURANCE OMBUDSMAN RULES, 2017)

INSURANCE OMBUDSMAN- Dr. D.K. VERMA

Case of Mr. Vivek Gogia V/S The United India Insurance Co. Ltd.

COMPLAINT REF. NO: CHD-H-051-2021-0492

1. Name & Address of the Complainant Mr. Vivek Gogia

E-3/3, Ground Floor, DLF Valley,

Panchkula, Haryana- 134107

Mobile No.- 8283883322

2. Policy No:

Type of Policy


0407002818P116956099

Group Health Policy

01.01.2018 to 31.12.2018



Mr.Vivek Gogia

M/s Pearson India Educ. Services Pvt Ltd.

4. Name of the insurer The United India Insurance Co. Ltd.

5. Date of Repudiation 17.12.18

6. Reason for repudiation Non submission of documents.

7. Date of receipt of the Complaint 22-12-2020

8. Nature of complaint Non settlement of claim

9. Amount of Claim Approx. 3.4 lacs

10. Date of Partial Settlement NA

11. Amount of relief sought Nil

12. Complaint registered under

Rule no: Insurance Ombudsman Rules,

2017

Rule 13 (1)(b) – any partial or total repudiation

of claim by an insurer

13. Date of hearing/place 23.02.2021/ Chandigarh/Through VC


For the Complainant Mr. Vivek Gogia

For the insurer Ms. Renu Kathuria

15 Complaint how disposed Award

16 Date of Award/Order 02.03.2021

17) Brief Facts of the Case:

On 22-12-2020, Mr. Vivek Gogia had filed a complaint that United India Insurance Company has rejected

his claim due to delayed submission of the only ‘pending document’ asked by the TPA, which was a

settlement letter from Railways (2nd insurance party) stating that the amount paid to the hospital by

them (though hospital had all the records of the money they had billed to railways and the balance

taken from the patient). This is something that they have checked themselves from the hospital.

As per complainant, he followed up with railways for the settlement letter, but as per them they could

provide the same only to the insurance company. After repeated reminders he received request letter

from insurance company on 17.07.19. Later railways had given the settlement addressed to Vipul only in

reply to his letter of request. He sent the scanned copy of same on 26.09.19 and also sent hard copy to

HIBS team. It is quite strange that the insurance company was asking him to get the letter from Railways

authority addressed to the insurance company. Since 26.09.19 the complete file is with TPA / Insurance

Company and after almost a year they received the shocking reply that such old claims cannot be

considered for re-opening.

On 24-12-2020, the complaint was forwarded to The United India Insurance Co. Ltd. Regional Office,

Chandigarh, for Para-wise comments and submission of a self-contained note about facts of the case,

which was made available to this office on 19.01.2021. The complainant was sent Annexure VI-A for

compliance, which reached this office on 01.01.2021.

As per SCN submitted by company, as per recommendations of TPA, DO had closed the claim on

17.12.2018 due to non submission of documents as the claim file cannot be remained open for an

indefinite period. The request of insured to reconsider the claim was denied by the competent authority

as the old claims cannot be considered for reopening.

18) Cause of Complaint:

a) Complainant’s argument: Insurance Company has delayed claim payment and also paid less

then payable claim.

b) Insurers’ argument: Insurance Company has already paid claim as per terms and conditions of

the policy.

19) Reason for Registration of Complaint:- within the scope of the Insurance Ombudsman Rules, 2017.

20) The following documents were placed for perusal.

a) Complaint to the Company b) Copy of Policy Document

c) Annexure VI-A d) Reply of the Insurance Company

21) Result of Personal hearing with both parties(Observations & Conclusion)

On perusal of various documents and submissions made by both parties during hearing held through

video conferencing it has been observed that health claim of patient Mrs. Shanta Gogia was closed by

insurance company vide letter dt. 17.12.2018 for non compliance of queries/documents which includes

settlement letter of already paid claim by Railways. The said settlement letter is issued by Medical

director, N.Rly. Central Hospital, New Delhi vide their letter dt. 23.09.19. Insurance company vide letter

dt. 18.11.2020 denied the request for reopening of closed file of complainant. After the complaint was

lodged with this office, insurance company has paid the said claim. Insurance company vide e-mail dt.

26.02.2021 informed that out of total billed amount of Rs. 995318/-, Rs. 653677/- was paid by railway,

Rs. 57010 is deducted for co-pay, Rs.4000/- deducted for face mask. After making initial payment of Rs.

228042/- insurance company has paid Rs. 42071, (Rs.52589 – 20% co-pay) on 25.02.2021 in the matter.

Complainant during hearing admitted receipt of claim of Rs. 228042/- paid by company. Further,

complainant vides e-mail dt.26.02.2021 informed that he received the balance deducted amount of Rs.

42000/- from the company and his claim has now been settled. Although he also requested for

compensation for the expenses incurred in travelling, mental stress, physical and mental harassment

along with bonafide interest on the delayed payment. I have seen all the relevant documents carefully

and it is evident that there has been a delay in settlement of claim by insurance company after receipt

of all documents from complainant tantamounting to deficiency in service. As such, insurance company

is directed to pay a lump sum amount of Rs. 8000/- as interest for delaying the claim payment of

complainant, within 30 days of receipt of award copy.

AWARD

Taking into account the facts & circumstances of the case and the submissions made by both the

parties during the course of on line hearing, Rs. 8000/- is hereby awarded to be paid by the

Insurer to the Insured as interest, for delaying the claim payment of complainant.

Hence, the complaint is treated as closed.

Dated at Chandigarh on 2nd day of March, 2021.

D.K. VERMA

INSURANCE OMBUDSMAN



Case of Mr. Harbhajan Singh V/S Cholamandalam MS Gen. Insurance Co. Ltd.

COMPLAINT REF. NO: CHD-G-012-2021-0655

1. Name & Address of the Complainant Mr. Harbhajan Singh

# 1410, Street No.-14,

Guru Nanak Nagar, Patiala, Punjab-0

Mobile No.- 9815937870

2. Policy No:

Type of Policy


2876/00044619/000043/000/01

Group Health Insurance

31.01.19 to 30.01.20



Mr. Inderjeet Singh/Ms. Rajinder Kaur

Mr. Harbhajan Singh

4. Name of the insurer Cholamandalam MS Gen. Insurance Co. Ltd.


6. Reason for repudiation Inpatient admission not required


8. Nature of complaint Repudiation of claim






2017





For the Complainant Mr.Harbhajan Singh

For the insurer Dr.Manish




On 16-02-2021, Mr. Harbhajan Singh had filed a complaint vide which he informed that his son

Inderjeet Singh and wife Rajinder Kaur has been admitted to hospital Vardhman Mahaveer health care

at Patiala with the diagnosis of COVID positive on 22 Sept 2020. He applied for claim to insurance

company, but they have declined his genuine claim of Rs.2,06,985/- of reimbursement.

On 19-02-2021, the complaint was forwarded to Cholamandalam MS Gen. Insurance Co. Ltd. Regional

Office, New Delhi, for Para-wise comments and submission of a self-contained note about facts of the

case, which was made available to this office on 09.03.2021. The complainant was sent Annexure VI-A

for compliance, which reached this office On 25.02.2021.

As per SCN submitted by insurance company, against the subject policy two claims were reported.

i) The claim of Smt. Rajinder Kaur bearing claim no. 2876022590 for reimbursement of hospitalization expenses at Vardhman Mahaveer Health Care Hospital for the period 22.09.20 to 30.09.20.

ii) The Claim of Mr.Inderjeet Singh bearing claim no. 2876022589 for reimbursement of hospitalization expenses at Vardhman Mhaveer Health Care Hospital for the period 22.09.2020 to 30.09.2020.

On perusal of both the claim documents, it was observed that the patients were stable, and as per the

MOHFW; CLINIICAL MANAGEMENT PROTOCOL : COVID 19(copy attached) such patient does not require

hospitalization and the treatment can be done in home quarantine. Further as per the policy, no

indemnity is available or payable for the claims beyond scope of policy coverage, Part B Section 1

(necessity of hospitalization). The hospitalization records of the patients reveal that the vitals were

stable. Hence as per the Govt. guidelines, hospitalization is not warranted for such patients, thus the

claim for hospitalization for the patients is clearly beyond the policy scope. Therefore the claim was

rightly repudiated by the insurer.


a) Complainant’s argument: Insurance company has not paid health claim related to COVID-19 of

his wife and son on flimsy grounds.

b) Insurers’ argument: Claims were repudiated as per terms and conditions of the policy.






On perusal of various documents and considering submissions made by both the parties during online

hearing it has been observed that health claims related to COVID-19 of Mrs. Rajinder Kaur &

Mr.Inderjeet Singh have not been paid by insurance company. Mrs. Rajinder Kaur, wife & Mr.Inderjeet

Singh, son of complainant, after being COVID-positive hospitalized in Vardhman Mahaveer Health Care,

Patiala from 22.09.20 to 30.09.20. As per company, they observed that the treatment given during the

hospitalization period doesn’t warrant inpatient admission and that can be treated in outpatient

department, which is outside scope of policy coverage under clause Part B Section 1. They added that

related documents suggest that vitals of all the members were stable and as per MOHFW guidelines

member did not require hospitalization and treatment could have been done under home quarantine,

hence claim has been denied. Complainant argued that the admissions were made as per advice of

treating doctors. Clinical management protocol for COVID -19 is advisories from government in specific

circumstances. Final call on requirement of hospitalization has to be made by treating doctor on the

basis of present condition, previous history, age of patient and other factors of the case. In current case,

patient Mrs. Rajinder Kaur has history of appendicitis. Moreover, treating doctor vide certificates

dt.11.11.20 has confirmed the necessity of hospitalization for both patients. In my opinion, being

layman, in the present scenario due to COVID-19, patients have not much option but to follow

instructions from treating doctor, which has been done in present case also. As such, admission of both

patients in hospital in above said case is very much justified and decision of insurance company to

repudiate their claims is unjustified. Accordingly, insurance company is directed to pay admissible claim

of Mrs. Rajinder Kaur & Mr. Inderjeet Singh to insured as per terms and conditions of the policy within

30 days of receipt of award copy.

AWARD


parties during the course of online hearing, admissible claims of Mrs. Rajinder Kaur & Mr. Inderjeet

Singh is hereby awarded to be paid by the Insurer to the Insured as per policy terms and

conditions, towards full and final settlement of the claim.


Dated at Chandigarh on 15th day of March, 2021.

D.K. VERMA

INSURANCE OMBUDSMAN



Case of Mr. Rajat Dhankar V/S The United India Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Rajat Dhankar

Punjab & Sind Bank, Manimajra, Chandigarh,

SCO-825, NAC, Manimajra, Chandigarh-0

Mobile No.- 9813587005

2. Policy No:

Type of Policy


5001002819P111088805

Group Health Policy

01-10-2019 to 30-09-2020



Mr. Rajat Dhankar

Indian Bank’s Association


5. Date of Repudiation NA

6. Reason for repudiation NA


8. Nature of complaint Deduction in claim

9. Amount of Claim Ded. Of Rs. 14094/-

10. Date of Partial Settlement Not provided

11. Amount of relief sought Amount deducted from bill



2017



13. Date of hearing/place 12.03.2021/ Chandigarh


For the Complainant Mr.Rajat Dhankhar

For the insurer Ms.Pamela Pinto




On 06-01-2021, Mr. Rajat Dhankar had filed a complaint against United India Insurance Company Ltd.

regarding unjustified deduction from claimed bill. He submitted his claim documents in first week of

December at ZO Punjab and Sind Bank. After various mail and telephone call they settled the claim on

07.03.2020. Complainant asked for payment of deduction made of Rs. 14094/- plus penalty and late

settlement of claim.




compliance, which reached this office on 18-01-2021.

As per SCN submitted by insurance company, they have issued a Group Mediclaim Policy to IBA –Punjab

and Sind Bank covering their employees alongwith their dependent member for the period 01.10.2019

to 30.09.2020. Sh.Rajat Dhankar alongwith dependent member Mrs. Richa (spouse) are included in the

above policy for S.I. of Rs. 400000 subject to LSCS Maternity limit of Rs. 75000/-. Company settled

G2P1L1 Pregnancy claim of Smt. Richa Dhama for Rs. 63690/- against claimed amount of Rs. 77784/-.

Deduction of Rs.14094/- has been made as under:

Item Head Deducted

Amount

Reason for deduction

Pre-post Natal Expenses 6107 Under Clause 3.5(ii) of policy terms and conditions

Consultation 600 Consultation Notes not submitted

US –Emergency charges 2400 Ref bill no.009307 dt.03.11.19 not payable as per

terms and conditions of the policy

150 Calculation error

Chemist Bill 3285 Chemist Bill dt.16.11.19 does not have GST Number as

required under clause 4.12 of policy

Chemist Bill 1552 Chemist Bill dt.16.11.19 does not have GST Number as

required under clause 4.12 of policy

Total 14094


a) Complainant’s argument: Insurance Company has wrongly deducted claim amount from

hospitalization claim of her wife.

b) Insurer’s argument: Deduction has made from claim as per terms and conditions of the policy.

19) Reason for Registration of Complaint: - within the scope of the Insurance Ombudsman Rules, 2017.




21) Result of Personal hearing with both parties (Observations & Conclusion)

On perusal of various documents and considering submissions made by both the parties during online

hearing it has been observed that in maternity claim of Mrs. Richa Dhama, insurance company has made

payment of Rs. 63,690/- against claimed amount of Rs. 77784/- after deduction of Rs.14094/- for which

complainant has made this complaint. I have seen the relevant documents and observed that Insurance

company rightly deducted for pre/post natal expenses under clause 3.5 (ii) of policy terms and

conditions which states that pre/post natal charges in respect of maternity benefit are covered under

the policy only if the same requires hospitalization. On careful examination of all deductions, it is seen

that insurance company has made deductions as per policy terms and conditions of the policy except

deduction of Rs.3285/- and Rs. 1552/- made due to non availability of GST number on chemist bill. These

bills relates to pharmacy shop within the Paras hospital where patient was hospitalized. Complainant

provided copy of GST registration certificate of Paras Health Care Pvt. Ltd. Moreover, as hospitalization

bill of same hospital has already been settled by company, their stand of deduction is not justified.

Accordingly insurance company is directed to pay balance claim amount of Rs. 4837/-(3285+1552) to

insured in above said claim as per policy terms and conditions within 30 days of receipt of award copy.

AWARD


parties during the course of personal hearing, balance claim amount of Rs.4837/- is hereby

awarded to be paid by the Insurer to the Insured, towards full and final settlement of the claim.



D.K. VERMA

INSURANCE OMBUDSMAN



Case of Mr. Surinder Kumar Khanduja V/S The United India Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Surinder Kumar Khanduja

Tower-B-3, Flat No.- 104, Surya Tower,

VIP Road, Zirakpur, Punjab- 140603

Mobile No.- 9876079213

2. Policy No:

Type of Policy


5001002819P112942762

Group Mediclaim Policy

01-11-2019 tom 31-10-2020



Mr.Surinder Kumar Khanduja

Indian Bank’s Association a/c UCO Bank


5. Date of Repudiation NA

6. Reason for repudiation NA


8. Nature of complaint Deduction in claim

9. Amount of Claim Rs. 52361/- (Partially paid)

10. Date of Partial Settlement Not provided

11. Amount of relief sought Rs.18000/-



2017





For the Complainant Mr.Surinder Kumar Khanduja

For the insurer Ms.Pamela Pinto




On 07-01-2021, Mr. Surinder Kumar Khanduja had filed a complaint vide which he informed that his

wife underwent for cataract surgery on 21.08.2020 and accordingly a reimbursement claim of Rs.

52361/- was lodged. The bills consists of hospitalization bill of Rs. 42000/-, Pre hospitalization bill of Rs.

7308/- and pharmacy bill of Rs. 3053/-. The TPA had settled the bill for Rs. 34361/- and made arbitrary

deduction of Rs. 18000/-. Despite his repeated requests the TPA has not provided him item wise

breakup of the amount approved and also not given satisfactory reply for deductions. He requested for

balance payment of Rs. 18000/-.




compliance, which reached this office on 15-01-2021.

As per SCN submitted by insurance company, Group Medical Policy was issued to IBA-UCO bank

covering their retired employees alongwith their dependent members for the period 01.11.2019 to

31.10.2019 with sum insured of Rs. 400000/-. Company has received claim for payment of

hospitalization at Laser Eye Clinic, Chandigarh for right eye cataract surgery with MICS. Against claimed

amount of Rs. 52361/- + Rs.1532 (per/post Hosp.), claim settled for Rs. 34361/- + Rs. 1532/- with

deduction of Rs. 18000/-. Company deducted Rs. 18000/- from bill for Rs. 42000/- as per prevailing PPN

rates for MICS cataract surgery in same geographical area. Hence the deductions are made as per

definition 2.44 of the policy which defines reasonable and customary charges as the charges for services

or supplies, which are the standard charges for the specific provider and consistent with the prevailing

charges in the geographical area for identical or similar services, taking into account the nature of

illness/injury involved. Claim has been settled as per Ahmadabad Municipal Corporation rates within the

sub limits specified in the terms and conditions of the policy.


a) Complainant’s argument: Insurance Company has made deduction in health claim of her wife

on wrong grounds.

b) Insurers’ argument: Deduction has been made as per terms and conditions of the policy.





21) Result of Personal hearing with both parties (Observations & Conclusion)

After examining documents submitted by both parties and considering submissions made by

complainant as well as representative of insurance company during online hearing, it has been observed

that in health claim of right eye cataract surgery of Mrs. Kiran Khanduja insurance company made

payment of Rs. 34561/- against claimed Rs. 52361/-. Deduction of Rs. 18000/- has been made by

company as per 2.44 of policy related with reasonable and customary charges. Insurance company

argued that Rs. 18000/- is deducted as per prevailing PPN rates for MICS cataract surgery in the same

geographical area. But company has not provided any proof of charges prevailing in that geographical

area in such type of treatment. Moreover PPN rates have not been specified for various ailment diseases

in the policy for different locations, as such insurance company cannot take the plea that the claim

amount being more than the PPN rate has to be deducted in this case. Insurance company arbitrarily

makes deductions, as rates of different hospitals may vary with infrastructure, locations and status of

treating doctors etc. As such decision of insurance company to make deduction on the basis of

reasonable and customary charges clause in above said claim is incorrect. Hence, company is directed to

pay balance admissible claim to insured as per terms and conditions of the policy within 30 days of

receipt of award copy.

AWARD


parties during the course of personal hearing, balance admissible claim is hereby awarded to be

paid by the Insurer to the Insured, towards full and final settlement of the claim.



D.K. VERMA

INSURANCE OMBUDSMAN



Case of Mr. Gaurav Gupta V/S Cholamandalam MS Gen. Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Gaurav Gupta

# 4515, I-Block, Darshan Vihar,

Sec-68,Mohali, Punjab-160062

Mobile No.- 9041833322

2. Policy No:

Type of Policy


2876/00021838/000002/000/01


07-09-2020 To 06-09-2021



Mr. Gaurav Gupta & Ms.Shail Gupta

Mr. Gaurav Gupta



6. Reason for repudiation Non disclosure of facts



9. Amount of Claim Rs. 5.0 Lacs


11. Amount of relief sought Rs. 5.0 Lacs



2017





For the Complainant Mr.Gaurav Gupta

For the insurer Dr.Manish Bata




On 16-02-2021, Mr. Gaurav Gupta had filed a complaint that insurance company has wrongfully denied

his mediclaim for treatment of Covid-19 of his mother, Mrs. Shail Gupta. This is the second year of his

policy and there is an error on the company’s part. As per complainant all the necessary details were

provided to the company at the time of buying the policy but the company is now saying that they have

not disclosed the facts, which is incorrect rather the company had not shared the duly signed proposal

form at the time of taking the policy. Even now company sent across an unsigned document. Further in

the e-mail dt. 28.01.2021, the company official has claimed that word ‘NIL’ is mentioned under PED

column on the policy certificate. However in the document sent across to him, word ‘NA’ is mentioned

and NIL is not mentioned anywhere. Furthermore the company is relying on policy T & C to inform him

that the policy is null and void however the same too was never shared with him. Due to company’

negligence, he left out to bear the medical expenses of approx. Rs.10 lacs at his own.




for compliance, which reached this office on 23.02.2021.

As per SCN submitted by company, one claim was reported with claim no. 2876025741 for pre

authorization request for cashless. The claim was repudiated on the ground of non disclosure of the

material information. On perusal of the documents, it is observed that the insured is a known case of

hypertension since 18 years as per history recorded in the discharge summary. The information is not

disclosed in the proposal form while proposing for insurance. In view of the non disclosure of material

information as per policy wording, the contract of insurance become void and no claim was payable

under the policy. Further, insured never come before the company for request of reimbursement of the

claim. Company also informed that policy was issued under Group Health Insurance and declaration of

proposal was received by the company in excel sheet. The column of pre-existing disease was blank in

the same. Company also refer a court judgment and claimed that claim of complainant was rightly

repudiated by the company.


a) Complainant’s argument: Insurance company has not paid health claim of her mother on the

basis of false grounds of misrepresentation of facts.

b) Insurers’ argument: Insurance Company has denied the claim as per terms and conditions of the

policy.





21) Result of Personal hearing with both parties (Observations & Conclusion):

As per discharge summary of hospital Chandigarh healthcare Pvt. Ltd., patient Ms. Shail Gupta remained

hospitalized from 18.11.2020 to 20.11.2020 with diagnosis as COVID 19 POSITIVE. Insurance company

denied cashless request for her health claim due to non-disclosure of facts. As per insurance company,

insured is a known case of hypertension since 18 years as per history recorded in discharge summary,

which is not disclosed in the proposal form while proposing for insurance. Accordingly through letter dt.

18.11.2020, cashless request is denied by company under general condition no. 11. Complainant denied

any misrepresentation and informed that neither he filed any proposal form, nor signed any such form. I

have seen all the relevant documents and observed that first of all hospitalization was due to COVID

Positive, which has no relation with hypertension. Treating doctor also in writing confirmed that this is a

case of COVID-19 which is not due to Hypertension. Further insurance company has failed to submit any

duly signed proposal form of the relevant policy to confirm misrepresentation on part of insured.

Moreover, copy of unsigned excel sheet submitted by insurance company as part of proposal form is

showing no data under column pre existing disease, which cannot be taken as misrepresentation on part

of insured. Keeping in view the facts of the case and above discussion decision of insurance company to

deny the claim is incorrect. Accordingly insurance company is directed to pay the admissible claim

amount to insured as per terms and conditions of the policy within 30 days of receipt of award copy in

above said case. Company is also directed to reinstate the said policy, if cancelled subject to submission

of due premium by insured.

AWARD


parties during the course of online hearing, admissible claim is hereby awarded to be paid by the

Insurer to the Insured, towards full and final settlement of the claim along with reinstatement of

policy, if cancelled.


Dated at Chandigarh on 22nd day of March, 2021.

D.K. VERMA

INSURANCE OMBUDSMAN



Case of Mr. Sita Ram V/S Tata AIG General Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Sita Ram

H. No.- 3104, Sector-25-D,

Chandigarh

Mobile No.- 9988202804

2. Policy No:

Type of Policy


0237868334041857

Group Medicare

29-10-2020 To 28-10-2021



Mr. Sita Ram

Axis Bank Limited

4. Name of the insurer HDFC ERGO General Insurance Co. Ltd.


6. Reason for repudiation Not payable due to two years waiting period.


8. Nature of complaint Denial of Hospitalization Expenses

9. Amount of Claim Rs. 58590/-

10. Date of Partial Settlement N.A




2017


of claims by an insurer

13. Date of hearing/place 15.03.2021/ online


For the Complainant Mr. Sanjay Kumar(Son)

For the insurer Mr. Dhiraj Mhatre



17). Brief Facts of the Case:

On 01-01-2021, Mr. Sita Ram had filed a complaint against HDFC ERGO General Insurance Co.

Ltd. for rejection of his mediclaim and submitted that complainant is holding the policy with the

insurer since Oct. 2019 and no claim has been claimed till now. Despite paying the regular

premium insurance company has rejected his claim for the wrong reason. The complainant

stated that he fell down at home at 10 days ago and there was injury in lower part of his body in

the ass hole. On examination doctor found trauma at ass hole and operated and removed the

infection from complainant’s body because of emergency. The Doctor also confirmed that

infection and trauma was caused due to fall at home as it was emergency surgery with the case

of accident but still the company rejected the claim with the reason of waiting period of 24

months. The complainant further stated that as it was emergency surgery with cause of accident

then how it would be under waiting period of 24 months. The complainant requested for

resolution of grievance against insurer regarding reimbursement of expenses amounting to

Rs.60000/- incurred by him on treatment.

On 07-01-2021, the complaint was forwarded to Tata AIG General Insurance Co. Ltd. Regional

Office, Noida, for Para-wise comments and submission of a self-contained note about facts of

the case, which was made available to this office on 25-01-2021.As per the SCN, the

complainant Mr. Sita Ram had obtained a tailor made Group Medicare Policy for sum insured of

Rs. 5 Lac for the period 29.10.2019 to 28.10.2020. This policy is tailor made for the customers of

axis bank with specific coverage as required by the bank and the policy was renewed for the

period 29.10.2020 to 28.10 2021 along with specific exclusion under section 3(ii) which is

relevant to the claim and is reproduced below;

Section 3- General Exclusions

Exclusions with waiting periods

ii) A waiting period of 24 months from the first policy commencement date will be applicable to

the medical and surgical treatment of illness, disease, or surgical procedures mentioned below,

unless necessitated due to cancer:

a. ……… n. Fissure/fistula in anus, hemorrhoids, pilonidal sinus

r. Perineal Abscesses

s. Perineal/Anal Abscesses

Insurer submitted that they had received a preauthorization request on 10th December 2020

indicating that Mr. Sita Ram had complaints of pain in anal region for 5-6 days with poor oral

intake and history of constipation. He was diagnosed as a case of Perianal Abscess with Fistula in

Ano for which he underwent Incision and Drainage with Fistulotomy.

Since Perianal abscess falls under2 years waiting period, insurer rejected the pre-authorization

vide letter dated 10th December 2020. Insurance company received the claim documents from

insured on 25.10.2020 with a diagnosis of ‘Perianal Abscess with Fistula in Ano’. Since Perianal

Abscess and Fistula in Ano surgery is not payable within first two years of policy inception, the

claim was rejected by insurer vide letter dated 28th December 2020. The customer produced a

document indicating that the Perianal Abscess and Fistula were related to an injury. Insurer

further stated that they highlighted to the complainant that the exclusion for Fissure and fistula

apply in case of injury. Insurer stated that History of trauma is an afterthought as neither the

preauthorization documents, emergency department initial assessment nor indoor case papers

of the hospital indicate any history of trauma. This was highlighted only after preauthorization

was denied and not any time prior. Also just a fall at the back does not generally cause Anal

fissure and fistula, trauma in the context of Fissure/Fistula is more common in the context of:

- Passage of hard stool - Repeated diarrhea - Anorectal surgery - In rare cases, it is due to Anoreceptive intercourse/ foreign body insertion. In the Para-wise reply the insurer submitted;

1. It is submitted that in preauthorization documents received, there was no where mentioned that insured has history of trauma or injury. Had the patient was really suffering from injury prior to admission treating doctor would have mentioned vigorously about date/time/place/nature of injury in the preauthorization form no 2 against question no K & L. Even if we were to consider the history of trauma/injury, it has no bearing on the case as the exclusion applies irrespective of the cause

2. It is submitted that in claim documents viz. discharge summary, indoor case papers it was nowhere that said ailment was attributed due to trauma. This was after thought from the insured that the said ailment was attributed due to trauma. The same has been evident from the reimbursement claim form page no. 2 against question “Hospitalization due to” there were 3 options viz. injury/illness/maternity, insured himself ticked on ‘illness’. He has not ticked against the “injury”. It suggests that insured never had any injury. Even in reimbursement claim form, on page 5, against question “Hospitalization due to injury” there were two options viz. Yes/No. treating doctor himself ticked on “No”. Hence it is evident that insured never had any trauma/injury.

3. It is submitted that complainant has presented a certificate from the treating doctor indicating that the indurations and infection could be due to an alleged fall. This neither mentioned in the, emergency department initial assessment nor in the indoor case papers of the hospital nor in the pre-authorization request or discharge summary. Even if we take this document into consideration, the claim would still not be admissible under the policy as the two years exclusions apply even in case of injury as per the tailor made policy issued to the Axis Bank.

4. It is submitted that even they were to consider the injury, Fistula in Anus are never an acute problem but due to long standing infection. The treating doctor has now clarified that the earlier certificate issued was based on the patient’s declaration of history of fall which was not given at the time of pre-authorization but later came up with this history. This letter is marked as Annexure 7. There are no external injuries which are noted in the critical documents viz. discharge summary and indoor case papers.

5. It is evident from the mail dated 29.12.2020 where he mentioned fall /injury was 3-4 days back from the date of admission & complainant letter submitted to Ombudsman by the complainant where he mentioned fall was 10 days back, this clearly shows that complainant is twisting facts and giving contradictory statements. The insurance company has sought dismissal of complaint as the claim falls under the

specific exclusion highlighted above even if this is due to an injury/trauma.

The complainant was sent Annexure VI-A for compliance, which reached this office on 22-01-

2021


a) Complainant’s argument: The denial of claim for Perianal Abscess with Fistula in Ano due to

24 months waiting period is not justified as emergency surgery was necessitated due to

accidental fall.

b) Insurers’ argument: The claim is not admissible due to specific exclusion under section

3(1)(ii) of the policy which is related with waiting period of 24 months from the first policy

inception.

19) Reason for Registration of Complaint: Within the scope of the Insurance Ombudsman Rules,

2017.




21) Result of Personal hearing with both parties (Observations & Conclusion):

On perusal of the various documents available in the file including the copy of the complaint,

SCN of the insurance company, discharge summary and submission made by both the

complainant and the insurance company during on line hearing, it has been observed that

complainant’s reimbursement claim under Mediclaim policy, for hospitalization at Max Super

Speciality Hospital from 09.12.2020 to 12.12.2020 for treatment of perianal abscess fistula in

ano, has been repudiated by the insurer under section 3)1)ii of the policy as the treatment falls

under two years specific waiting period.

The complainant stated that denial of claim for perianal abscess with Fistula in Ano due to 24

months waiting period is not justified as emergency surgery was necessitated due to accidental

fall.

The representative of the insurer stated that claim is for perianal abscess which has a specific

two years of waiting period as per the policy and the policy start date is 29th October .Hence the

claim is repudiated under section 3)1)ii of the policy.

As per the discharge summary, the complainant during the hospitalization on 09.12.2020 was

treated for perianal abscess with fistula in Ano. Complainant’s argument that treatment was

necessitated due to history of trauma few days ago cannot be relied as there is no mention of

the same in the discharge summary which is an authentic piece of evidence with regard to the

cause, past history and treatment given to patient during hospitalization. Doctor’s undated

certificate issued subsequently to discharge of patient seems to have been procured to justify

that treatment of insured was due to accidental injury. As per section 3 General Exclusions of

the policy terms and conditions, expenses incurred on medical and surgical treatment of

illnesses, disease or surgical procedures for Perianal abscess and fistula in Anus are not payable

within 24 months from the policy inception which in the case of complainant is

29.10.2019.Therefore, the claim denial decision of the insurance company that treatment of

ailment falls within exclusion clause of 24 months, from the policy inception date, is in order as

per policy terms & conditions and does not warrant any interference. The complaint is dismissed

being devoid of merits and no relief is granted.

ORDER

Considering the facts & circumstances of the case and the submissions made by both the

parties during online hearing, the complaint is hereby dismissed being devoid of merits.


Dated at Chandigarh on 18th day March 2021.

D.K. VERMA

INSURANCE OMBUDSMAN



Case of Mr. Mahesh Chandra Joshi V/S The Oriental Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Mahesh Chandra Joshi

C1/2821, SF, Sushant Lok-1, Gurugram,

Haryana- 122009

Mobile No.- 9650200266

2. Policy No:

Type of Policy


272400/48/2020/2111


16-06-2020 To 15-06-2021



Mr. Mahesh Chandra Joshi

4. Name of the insurer The Oriental Insurance Co. Ltd.

5. Date of Repudiation N.A

6. Reason for repudiation N.A


8. Nature of complaint Unrealistic increase in premium

9. Amount of Claim N.A

10. Date of Partial Settlement N.A

11. Amount of relief sought Refund of Premium Rs.37971/-



2017

Rule 13 (1)(c) – any dispute in regard to

premium paid or payable in terms of policy.

13. Date of hearing/place 15.03.2021/ Online


For the Complainant Mr. Mahesh Chandra

For the insurer Mr. Anil Nagpal

15 Complaint how disposed Dismissed



On 04-01-2021, Mr. Mahesh Chandra Joshi had filed a complaint against The Oriental Insurance

Co. Ltd for increase of mediclaim premium and stated that The oriental insurance company

limited and Punjab National Bank Jointly started a PNB-Oriental Mediclaim Policy ( A group

health insurance product for the account holders of PNB only. The complainant being a PNB

account holder joined this scheme on 16.06.2010 for himself and spouse both senior citizens

and took policy for sum insured of Rs.500000 for which he had been paying a fixed premium of

Rs.6930/- till June 2017. However, when the complainant went to pay the premium in June 2018

for 2018-19, the complainant was told that the premium has been revised to Rs.19587/-, an

increase of more than 280%. Since the complainant had to continue his mediclaim policy so had

no alternative but to pay the revised unreasonable premium for 2018-19 and have been paying

since then.

Since this was a specified scheme where insured don’t get any No Claim Bonus as well as there is

no reimbursement of yearly health check up, the complainant strongly feel that an increase of

premium amount by more than 280% is unrealistic. The complainant has sought the

intervention of this forum for refund of unreasonable increased premium amount

On 07-01-2021, the complaint was forwarded to The Oriental Insurance Co. Ltd. Regional

Office, New Delhi, for Para-wise comments and submission of a self-contained note about facts

of the case, which was made available to this office on 26.02.2021. As per SCN, the insured has

renewed his policy through online vide policy No.272400/48/2021/2023 for the period

16.06.2020 to 15.06.2021 and online premium paid by Rs.19587/- on 25.05.2020. It is submitted

that the product PNB Oriental Mediclaim Policy was launched by the insurer in 2010 and this

was a tie up arrangement with PNB and Oriental Bank of Commerce for customers having their

account with these banks. The policy terms and conditions were duly approved by the IRDA

after filing of same with them. Now the product was revised in the year 2017 and rates were

also revised by the insurer which is also on approval from IRDA. The insured has been paying

revised premium since 2018 and his previous policy no’s are 272400/48/2019/2536,

272400/48/2020/2111. Ours is a public sector undertaking and premium and policy terms are

duly approved by IRDA and premium charged by insurer are according to above guidelines.

The complainant was sent Annexure VI-A for compliance, which reached this office on 18-01-

2021.


a) Complainant’s argument: The increase in the premium under the PNB Oriental Mediclaim

Policy by the insurer is unrealistic and without any justification.

b) Insurers’ argument: Ours is a public sector undertaking where premium & policy terms are

duly approved by IRDA and premium charged by insurer is according to IRDA guidelines.

19) Reason for Registration of Complaint: Within the scope of the Insurance Ombudsman Rules,

2017.




21) Result of Personal hearing with both parties (Observations & Conclusion): On perusal of the

various documents available in the file including the copy of the complaint, SCN of the insurer and

submission made by both the complainant and the insurance company during the online hearing, it

has been observed that the complainant is seeking refund of premium on account of unrealistic

increase in premium charged by the insurer under the PNB-Oriental Mediclaim Policy.

The complainant stated that his mediclaim policy is under a specified scheme where they don’t get

any No Claim Bonus as well as there is no reimbursement of yearly health checkup. The complainant

strongly feels that an increase of premium amount by more than 280% is unrealistic.

The representative of the insurer stated that ours is a public sector undertaking where premium &

policy terms are duly approved by IRDA and premium is charged by them according to IRDA

guidelines.

The basic issue before me is to decide whether the insurer can revise the premium and policy terms

under any Mediclaim policy launched by them. As per section 6 of Health Insurance Regulation 2016

of IRDAI, insurers are authorized for review of health insurance products and apply for revision

under product filing guidelines subject to the provisions of the regulation 10 of these regulations

related to Principles of pricing of health insurance products. As the complainant himself has opted

for the insurance product sold by the insurer, which according to insurer is duly approved as per

IRDAI guidelines, no refund can be allowed to the complainant for the enhanced premium.

Therefore, complainant is dismissed being devoid of merits.

ORDER

Considering the facts & circumstances of the case and the submissions made by both the parties

during the course of hearing, the complaint is hereby dismissed being devoid of merits.

Hence the complaint is treated as closed.


D.K. VERMA

INSURANCE OMBUDSMAN



Case of Mr. Bishwanah Mukherjee V/S Cholamandalam MS Gen. Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Bishwanah Mukherjee

S/o Sh. Samir Kumar Mukherjee, 3266, Block-C,

Ground Floor, Front Back Side, Near

Gurudwara, Green Field Colony, Faridabad,

Haryana- 121010

Mobile No.- 9873171339

2. Policy No:

Type of Policy


2842/00178005/0002/000/00

Group Health Policy

12-04-2019 To 11-04-2020



Sh. Samir Kumar Mukherjee

Sh. Samir Kumar Mukherjee



6. Reason for repudiation PED



9. Amount of Claim Rs.326185 (9265+242305+74615)


11. Amount of relief sought Not provided



2017



13. Date of hearing/place 23.03.2021/ Chandigarh/Online Hearing


For the Complainant Mr.Bishwanath Mukherjee

For the insurer Dr.Manish Bata




On 12-01-2021, Mr. Bishwanah Mukherjee had filed a complaint that his father Mr.Samir Kumar

Mukherjee was admitted in the hospital on 7th March, 2020 as a case of Acute Stroke(Acute left MCA

infarct). During hospitalization pre-approval was rejected by insurance company without any

justification/evidence. On the company’s advice on 19th March, 2020 his father was discharged from the

hospital and accordingly they had paid all the bills. After discharge, they compile all bills and medical

test reports from hospital for further submission to insurance company for reimbursement process.

Suddenly there was completely lockdown due to COVID-19 and after unlock they had submitted all

original documents. In mid-july, insurance company send claim rejection mail mentioning reason of pre-

existing disease. Besides this, they had submitted total claim amount including pre-hospitalization,

hospitalization and post hospitalization expenses bill as per terms and rules but company mentioned the

claimed amount only for hospitalization in their claim repudiation letter. After reviewing the complete

case, Dr.Kunal Bahrani, (DM, Neutolagy, AIIMS) under whom the patient was admitted in the hospital

provided a letter which clearly certify that during admission and hospitalization period of complete 13

days, the patient’s BP was observed quite stable. He requested for reimbursement of his claim.




for compliance, which reached this office on 19.01.2021.

As per SCN submitted by company, one claim in respect of hospitalization of insured at Asian Institute of

Medical Sciences from 07.03.2020 to 19.03.2020 with regard to treatment of ‘Acute Left Mca Territory

infaract for medical mgmnt.’ was lodged. On perusal of documents it is observed that the signs and

symptoms of the present ailment is the complication of hypertension which were existing since 3 years,

which is prior to the inception of policy ( 12.04.2019 ) . Hence present ailment is considered as pre-

existing disease and the claim is inadmissible as per General Exclusion clause 3.2 which reads as No

indemnity is available or payable for claims directly or indirectly caused by arising out of or connected to

any pre-existing condition benefits will not be payable for any condition(s) as defined in the policy until

24 consecutive months of coverage for the insured person have elapsed, since inception of the first

policy with the insurer.’ The fact of pre existing disease was confirmed on a letter by the patient’s family

members. As per this letter, Sh.Samir Kumar had history of hypertension since 2-3 years. As such claim

of complainant was not found tenable under aforesaid clause of the policy and claim of complainant was

repudiated vide letter dt. 18.07.2020.


a) Complainant’s argument: Insurance company has rejected health claim of his father on wrong

grounds.

b) Insurers’ argument: Claim has been repudiated as per terms and conditions of the policy.






Considering submissions made by complainant and representative of insurance company in online

hearing and on perusal of various documents placed on record it has been observed that Mr.Samir

Kumar Mukherjee, father of complainant hospitalized from 07.03.2020 to 19.03.2020 in Asian Institute

of Medical Sciences with diagnosis of acute left MCA territory infaract – M1 Occlusion, left ICA complete

occlusion. His health claim has been denied by insurance company. As per repudiation letter dt.

18.07.20 issued by company, it is observed that that signs and symptoms of the present ailment (Acute

Left MCA territory infarct) is the complication of hypertension which was existing since 3 years, which is

prior to the inception of policy. Hence present ailment is considered as pre existing disease and the

claim is inadmissible as per general exclusion clause 3.2. Insurance company underlined in hearing that

during investigation, pre-existing disease of patient was confirmed by his family member in writing

stating that Mr.Samir Kumar had history of hypertension since 2-3 years. Although, complainant denied

the charges of PED. I have seen the discharge summary which is showing no history of hypertension.

Moreover during hospitalization period, different parameters remained stable like BP of patient is

110/80 mmHg, Pulse 72/ min and echo report is showing normal cardiac chamber dimension. Even

treating doctor in writing confirmed that patient Mr.Samir Kumar Mukherjee had no pre existing disease

prior to admission / stroke as per records and patient’s BP was quite stable during hospitalization.

Company has not produced any concrete evidence of PED and relying only upon statement of a relative

which is not justified. Moreover, brain stroke can happen due to reason other than hypertension also.

Considering all facts and discussion, decision of insurance company to repudiate the above said claim is

incorrect. Accordingly insurance company is directed to pay admissible claim to insured as per terms and

conditions of the policy within 30 days of receipt of award copy.

AWARD


parties during the course of personal hearing, admissible claim is hereby awarded to be paid by

the Insurer to the Insured, towards full and final settlement of the claim.


Dated at Chandigarh on 23rd day of March, 2020.

D.K. VERMA

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF ODISHA, BHUBANESWAR

(UNDER RULE NO: 16(1)/17 OF THE INSURANCE OMBUDSMAN RULES, 2017) OMBUDSMAN – Shri Suresh Chandra Panda

CASE OF Mr. K. Tirumala Kumandan Vrs. Cholamandalam MS Genaral Insurance Co. Ltd

COMPLAINT REF: NO: BHU-H-012-2021-0140

AWARD NO: IO/BHU/A/HI/ /2020-21


Mr. K. Tirumala Kumandan, Ammabhagavan Nilayam, Vidyanagar 2nd lane, Rayagada-765001. Odisha. Mobile No. 9437339292

2 Policy No: Type of Policy Duration of policy/Policy period

2876/00052985/000008/000/00. Group Health Insurance 04/03/2020 to 03/03/2021 (SI Rs. 5.00 lakh Floater) Date of admission 26/08/2020 D.O.D 07/09/2020


Mr. K. Tirumala Kumandan Mrs. Kothakota Aruna

4. Name of the insurer Cholamandalam MS Genaral Insurance Co. Ltd

5. Date of Repudiation 17/10/2020 Non-disclosure of material information 6. Reason for repudiation

7. Dt of receipt of the Complaint

05/01/2021

8. Nature of complaint Requested to advice the Insurer to settle the claim

9. Amount of Claim Rs. 2,40,641/-

10. Date of Partial Settlement Not applicable

11. Amount of relief sought Rs 2,40,641/-

12. Complaint registered under Rule no: of IO rules

13(1)b of IO rules

13. Date of hearing/place 05/03/2021 Bhubaneswar


a) For the Complainant Self through VC

b) For the insurer Mr. Rabi Prasad Khilani, Sr. Manager through VC

15 Complaint how disposed U/R 17 of the Insurance Ombudsman Rules, 2017


17. a. Brief Facts of the Case/Cause of Complaint: - The Complainant Mr K. Tirumala Kumandan covered under policy No. 2876/00052985/000008/000/00 for the period from 04/03/2020 to 03/03/2021 having floater sum insured of Rs. 5,00,000/-. He was hospitalised from 26/08/2020 to 07/09/2020 in Pradhama Multi Specialist Hospitals & Research Institute Ltd, Visakhapatanam for COVID-19 treatment. Then he lodged a claim for reimbursement of hospital expenses which was repudiated for the reason, non-disclosure of material information. Being aggrieved with repudiation, the complainant made an appeal before this forum for redressal. b. The insurer in their self-contained note stated that subject mentioned policy was issued to customers of Bank of Baroda (Group Insurance Policy) for the period from 04/03/2020 to 03/03/2021 subject to terms and conditions of the policy. On receipt of claim documents from the complainant they have registered the claim vide No. 2876020521 and immediately appointed service provider M/s. GRAVITY INTEGRATES PVT LTD on 17/09/2021 to facilitate the processing of the above claim. On perusal of documents submitted by the complainant, it is observed that the patient was suffering from fever from 19/08/2020 for which she visited DHH Rayagada. Her COVID test report came positive, but for better treatment she visited Pradhma Hospital, Visakhapatnam on 26/08/2020 and got admitted there. The CT report of Thorax done on 26/08/2020 showed the impression of small sub pleural module at ant Segment of Rt Upper lobe. He was treated conservatively in the hospital, and got discharged on 07/09/2020. The patient has H/O DM since last 7 years and is in medications, which was not disclosed in the

proposal form while proposing for insurance. In view of this non-disclosure of material information, the contract of insurance becomes void and no claim is payable under this policy. 4.20 Misdescription: - This policy shall be void and all premium paid hereon shall be forfeited to the company, in the event of misrepresentation, mis-description or non-disclosure of any material fact by the insured person(s). 18. a. Complainant’s Argument: At the time of proposing the insurance he has no such diabetes symptom. The agent of the company after making all enquiries and being satisfied accepted the proposal. Insurer’s Argument: Due to Non-disclosure of material information they repudiated the claim as per clause 4.20 of the policy. 19. Reason for Registration of Complaint: Scope of the Insurance Ombudsman Rules, 2017 20. The following documents are placed in the file.

a. Certificate of Insurance b. Photo copy of medical report and bills.

21. Result of hearing with both parties (Observations & Conclusion): - This Forum has carefully gone through all the documents and papers relating the complaint and heard both the parties. The Insurer informed that the insured was suffering from Diabetes for 7 years as per history recorded in the documents, which was not disclosed in the proposal form for which claim is not payable. The Insured informed that sample for covid testing was given at Rayagada on 21/08/2020 and as per test report dated 24/08/2020 he was found POSITIVE. For better treatment he was admitted as an indoor patient on 26/08/2020 and discharged on 07/09/2020. But the insurer declined the claim. 22. The attention of the complainant and the Insurer is hereby invited to the following provisions of Insurance Ombudsman Rule,2017: a. According to Rule 17(6) of Insurance Ombudsman Rules,2017, the Insurer shall comply with the award within 30 days of the receipt of the award and shall intimate the compliance of the same to the Ombudsman, b. As per Rule 17(8) of the said rules, the award of Insurance Ombudsman shall be binding on the Insurers. Dated at Bhubaneswar on the 5th day of March, 2021 INSURANCE OMBUDSMAN

FOR THE STATE OF ODISHA

AWARD

Taking into account the facts and circumstances of the case and submissions made by

both the parties during the course of hearing, the forum observed that the insurer

failed to provide any sufficient documentary evidence proving the insured had Diabetes

for last seven years and therefore, the denial of the claim is not correct. Therefore, the

Insured is entitled to get reimbursement for the amount incurred except non-allowable

items/expenses under the policy like sanitation, food, PPE kit, admission charges etc.

Therefore, the insurer is directed to pay the complainant a sum of Rs.1,72,081/- (one lac

seventy-two thousand eighty-one only) towards full and final settlement of the case.

Accordingly, complaint is allowed.

PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATE OF ODISHA, BHUBANESWAR (UNDER RULE NO: 16(1)/17 OF THE INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN – Shri Suresh Chandra Panda

CASE OF Mrs. Kothakota Aruna Vrs. Cholamandalam MS Genaral Insurance Co. Ltd COMPLAINT REF: NO: BHU-H-012-2021-0139



Mrs. Kothakota Aruna W/o Kothakata Tirumala Kumandan, Ammabhagavan Nilayam, Vidyanagar 2nd lane, Rayagada 765001. Odisha. Mobile No 8917561541


2876/00052985/000008/000/00 Group Health Insurance 04/03/2020 to 03/03/2021 SIV Rs.5.00 lakh Date of admission 26/08/2020 D.O.D 07/09/2020


Mrs. Kothakota Aruna Mrs. Kothakota Aruna


5. Date of Repudiation 12/10/2020 Non-disclosure of material information 6. Reason for repudiation


05/01/2021


9. Amount of Claim Rs. 92,584/-+ ambulance & transportation charges


11. Amount of relief sought Rs 92,584/-+ ambulance & transportation charges


13(1)b

13. Date of hearing/place 05/03/2021, Bhubaneswar


a) For the Complainant Husband of Insured Mr K.T.Kumandan, through VC

b) For the insurer Mr Rabi Prasad Khilani, Sr Manager through VC



17. a. Brief Facts of the Case/Cause of Complaint: - The Complainant Mrs Kothakota Aruna is covered under policy No. 2876/00052985/000008/000/00 for the period from 04/03/2020 to 03/03/2021 having floater sum insured of Rs. 5,00,000/-. She was hospitalised from 26/08/2020 to 07/09/2020 in Pradhama Multi Specialist Hospitals & Research Institute Ltd, Visakhapatanam for COVID-19 treatment. Then she lodged a claim for reimbursement of hospital expenses which was repudiated for the reason, non-disclosure of material information. Being aggrieved with repudiation, the complainant made an appeal before this forum for redressal. b. The insurer in their self-contained note stated that subject mentioned policy was issued to customers of Bank of Baroda (Group Insurance Policy) for the period from 04/03/2020 to 03/03/2021 subject to terms and conditions of the policy. On receipt of claim documents from the complainant they have registered the claim vide No. 2876020513 and immediately

appointed service provider M/s. GRAVITY INTEGRATES PVT LTD on 17/09/2021 to facilitate the processing of the above claim. On perusal of documents submitted by the complainant, it is observed that the patient was suffering from fever from 19/08/2020 for which she had her COVID test in DHH Raygada, Her COVID test report came positive, but for better treatment she visited Pradhama Hospital Visakhapatanam on 26/08/2020 and got admitted there. The CT report of Thorax done on 26/08/2020 showed the impression of Fibrotic stand at Lateral Segment of Lt Lower lobe. She was treated conservatively in the hospital, and got discharged on 07/09/2020. The patient had H/O/HTN since 5 years, DM T2 and Thyroid for more than 5 years This information was not disclosed in the proposal form while proposing insurance. In view of this non-disclosure of material information the contract of insurance becomes void and no claim is payable under this policy. 4.20 Misdescription: - This policy shall be void and all premium paid hereon shall be forfeited to the company, in the event of misrepresentation, mis-description or non-disclosure of any material fact by the insured person(s). 18. a. Complainant’s Argument: The non-disclosure clause is not attracted for the instant case and also the authorised agent of the company has filled the forms and made enquiries. After being satisfied accepted the proposal and issued the policy. Insurer’s Argument: Due to Non-disclosure of material information they repudiated the claim as per clause 4.20 of the policy. 19. Reason for Registration of Complaint: Scope of the Insurance Ombudsman Rules, 2017 20. The following documents are placed in the file.

a. Certificate of insurance b. Photo copy of medical report and bills.

21. Result of hearing with both parties (Observations & Conclusion): - This Forum has carefully gone through all the documents and papers relating the complaint and heard both the parties. The Insurer, during the hearing, informed that the insured was suffering from H/O HTN, DM T2 and Thyroid for 5 years as per history recorded in the submitted documents, which was not disclosed in the proposal form and therefore, the claim is not payable under non-disclosure of facts. The Insured informed that sample for covid testing was given at Rayagada on 21/08/2020 where she was found POSITIVE vide report given on 24/08/2020 and for better treatment she was admitted on 26/08/2020 and was discharged on 07/09/2020. The complainant stated that the denial of the claim has no basis.

AWARD


both the parties during the course of hearing, the forum observed that the insurer

failed to provide any sufficient documentary evidence proving the insured had

Diabetes for last seven years and therefore, the denial of the claim is not correct.

Therefore, the Insured is entitled to get reimbursement for the amount incurred

except non-allowable items/expenses under the policy like sanitation, food, PPE kit,

admission charges etc. subject to policy limits in terms of room rent etc. The

complainant shall be paid room-rent @ Rs.4000/- and not Rs.6000/-per day. Therefore,

the insurer is directed to pay to the complainant a sum of Rs.57,712/- (Fifty-seven

thousand seven hundred twelve only) towards full and final settlement of the

claim/case.


22. The attention of the complainant and the Insurer is hereby invited to the following provisions of Insurance Ombudsman Rule,2017:- a. According to Rule 17(6) of Insurance Ombudsman Rules,2017, the Insurer shall comply with the award within 30 days of the receipt of the award and shall intimate the compliance of the same to the Ombudsman and b. As per Rule 17(8) of the said rules, the award of Insurance Ombudsman shall be binding on the Insurers. Dated at Bhubaneswar on the 5th day of March, 2021 INSURANCE OMBUDSMAN




CASE OF Ms. Kothakota Bhavana Kumandan Vrs. Cholamandalam MS Genaral Insurance Co. Ltd

Complaint Ref No- BHU-H-012-2021-0138 AWARD NO: IO/BHU/A/HI/ /2020-21


Ms. Kothakota Bhavana Kumandan, D/o Kothakata Tirumala Kumandan, Ammabhagavan Nilayam, Vidyanagar 2nd lane, Rayagada-765001. Odisha. Mobile No. 6370655422


2876/00052985/000008/000/00. Group Health Insurance 04/03/2020 to 03/03/2021 (SIV Rs.5.00 lakh) Date of admission 26/08/2020 D.O.D 07/09/2020


Ms. Kothakota Bhavana Kumandan Mrs.Kothakota Aruna


5. Date of Repudiation 12/10/2020 Treatment given during hospitalisation period does not warrant inpatient admission.

6. Reason for repudiation


05/01/2021


9. Amount of Claim Rs. 92,584/-+ ambulance & transportation charges


11. Amount of relief sought Rs 92,584/-+ ambulance & transportation charges

12. Complaint registered under 13(1)b

Rule no: of IO rules



a) For the Complainant Father of complainant Mr K.T.Kumandan, through VC

b) For the insurer Mr Rabi Prasad Khilani, Sr Manager through VC



17. a. Brief Facts of the Case/Cause of Complaint: - The Complainant Ms Kothakota Bhavana is Kumandan covered under policy No. 2876/00052985/000008/000/00 for the period from 04/03/2020 to 03/03/2021 having floater sum insured of Rs. 5,00,000/-. She was hospitalised from 26/08/2020 to 07/09/2020 in Pradhama Multi Specialist Hospitals & Research Institute Ltd, Visakhapatanam for COVID-19 treatment. Then she lodged a claim for reimbursement of hospital expenses which was repudiated for the reason, the treatment given during hospitalisation period does not warrant inpatient admission. Being aggrieved with repudiation, the complainant made an appeal before this forum for redressal. b. The insurer in their self-contained note stated that subject mentioned policy was issued to customers of Bank of Baroda (Group Insurance Policy) for the period from 04/03/2020 to 03/03/2021 subject to terms and conditions of the policy. On receipt of claim documents from the complainant they have registered the claim vide No. 2876020519 and immediately appointed service provider M/s. GRAVITY INTEGRATES PVT LTD on 17/09/2021 to facilitate the processing of the above claim. On perusal of documents submitted by the complainant, it is observed that the patient was suffering from fever from 19/08/2020 for which she had her COVID test in DHH Raygada, which came out to be negative. The symptoms were not subsiding so she visited Pradhma Hospital on 26/08/2020. There her COVID test came out positive and so she was admitted there till 07/09/2020. The CT report of the thorax showed no abnormal findings, and she was treated conservatively there. The patient has H/O Asthma since 5 years and uses inhaler when in need, as per doctor’s advice. In view of above observations and on perusal of claim documents, it is observed that the treatment given during the hospitalisation period does not warrant inpatient Admission and can be treated in outpatient department. No indemnity is available or payable which is outside the scope of the policy coverage part A. which reads as “If the insured is diagnosed with an illness or suffers accidental bodily injury which necessitates his hospitalisation and the insurer will reimburse the insured persons consequent hospitalisation expenses.” IN the absence of any illness necessitating the hospitalisation as specified in this coverage, the claim is inadmissible. 18. a. Complainant’s Argument: Repudiation is most absurd and highly arbitrary and without valid reasoning. b. Insurer’s Argument: it is observed that the treatment given during the hospitalisation period does not warrant inpatient Admission and can be treated in outpatient department hence they repudiated the claim. 19. Reason for Registration of Complaint: Scope of the Insurance Ombudsman Rules, 2017 20. The following documents are placed in the file.

a. Certificate of insurance

b. Photo copy of medical report and bills.

21. Result of hearing with both parties (Observations & Conclusion): - This Forum has carefully gone through all the documents and papers relating the complaint and heard both the parties. The Insurer during VC informed that the patient had ASTHAM since 5 years and had been using inhaler and in this case, the patient did not warrant for admission as an in-patient as he could have been treated as an outpatient in OP department. The Insured informed that covid test was conducted at Rayagada on 21/08/2020 and was found POSITIVE as per report dated 24/08/2020. He was admitted as an indoor patient on 26/08/2020 and discharged on 07/09/2020, accordingly the claim is payable under the policy. 22. The attention of the complainant and the Insurer is hereby invited to the following provisions of Insurance Ombudsman Rule,2017: - a. According to Rule 17(6) of Insurance Ombudsman Rules,2017, the Insurer shall comply with the award within 30 days of the receipt of the award and shall intimate the compliance of the same to the Ombudsman and b. As per Rule 17(8) of the said rules, the award of Insurance Ombudsman shall be binding on the Insurers. Dated at Bhubaneswar on the 5th day of March, 2021 INSURANCE OMBUDSMAN




CASE OF Mr. Debendranath Barik Vrs. The New India Assurance Co. Ltd

COMPLAINT REF: NO: BHU-H-049-2021-0144 AWARD NO: IO/BHU/A/HI/ /2020-21

AWARD


both the parties during the course of hearing, the forum observed that the argument of

the insurer that the insured could have been treated as an outpatient is not acceptable

as the patient had Covid +ve as per ICMR report and he was admitted as per doctor’s

advice. Therefore, the insured is entitled to get the claim under the policy subject to

policy terms and conditions. The patient is entitled for room-rent @ Rs.4000/- and not

Rs.6000/- per day. Therefore, the insurer is directed to pay the complainant a sum of

Rs.57,384/- (Fifty-seven thousand three hundred eighty-four only) towards full and final

settlement of the claim/case.



Mr. Debendranath Barik, C/O Kunja Bihari Barik, AT/PO; Tala Telenga Bazar, Cuttack-753009. Odisha. Mobile No. 9437290202


Policy No- 0210002817P100575436, Claim No. HH531801096. Group Health Insurance The claim is admitted by the insurer.


Mr. Kunja Bihari Barik Mr. Kunja Bihari Barik

4. Name of the insurer The New India Assurance Co. Ltd

5. Date of Repudiation Not repudiated Not applicable. 6. Reason for repudiation


18/01/2021


9. Amount of Claim Rs. 19,800 + interest


11. Amount of relief sought Rs 19,800 + interest


13(1)b



a) For the Complainant Absent. Office could not reach him also over phone.

b) For the insurer MAQ Baig, AM



17. a. Brief Facts of the Case/Cause of Complaint: - The Complainant’s father Mr. Kunja Bihari Barik is covered under retired staff Mediclaim policy of the New India Assurance Co. Ltd, and has lodged a claim for reimbursement of hospital expenses. The claim was approved for Rs.19,800/- by the Heritage Health TPA but was not disbursed to the complainant in spite of repeated requests by the complainant. Being aggrieved the complainant made an appeal before this forum for redressal. In the meantime, on 10.02.2021, the insurer paid the claim for Rs. 19712/-. Subsequently on 15/03 2021 the complainant submitted this office a statement of expenses for Rs.36,150/- along with copy of medicine bills, Laboratory bills without supporting prescription /investigation report. b. The insurer in their self-contained note stated that the aforesaid claim was intimated to M/s. Heritage Health TPA on 22nd December,2017 and claim papers were submitted on 5th December, 2018.The claimed amount was Rs.35,907/- out of which Rs.16,195/- were not allowed by TPA, being the items are not covered under the policy, hence an amount of Rs.19,712/- was approved. The services of TPA was discontinued w.e.f. 1st Apriil,2018. Due to change of TPA, the claim remained unpaid at the end of M/s. Heritage TPA. However, on 10/02/2021 the claim was paid for Rs.19,712/- and the amount transferred to the account of Mrs. Basanti Barik, the spouse of the patient (deceased) vide NEFT No. 42211404158688. Medical officer’s review sheet for deduction of Rs.16,195/- are appended below. 1. Report not submitted (1670 + 1800 + 400 + 1800) = Rs.5670/- 2. 50% non-payable items deducted from cashless = Rs.7,023/- 3. Post hospitalisation gloves not payable = Rs. 25/- 4. Diaper ch. Not payable = Rs.3,250/-

5. 60 days after D.O.D. = Rs. 227/- TOTAL Rs.16,195/- 18. a. Complainant’s Argument: Though the claim was approved by the TPA but payment was not released in spite of repeated reminders. Bills submitted for Rs.36150/- but settled for Rs.19,712/- is unjustified. b. Insurer’s Argument: Deductions were made as per policy conditions and claim was delayed due to change of TPA 19. Reason for Registration of Complaint: Scope of the Insurance Ombudsman Rules, 2017 20. The following documents are placed in the file.

a. Policy copy and clauses b. Photo copy of medical report and bills.

21. Result of hearing with both parties (Observations & Conclusion): - This Forum has carefully gone through all the documents and papers relating the complaint and heard the insurer in absence of the complainant as he was not present in spite of notice and telephonic information about the date of hearing. It is observed that the complainant was chasing the insurer for settlement of the claim as per the assessment made by the TPA, who was changed by the insurer later on. But the insurer did not settle the claim until the complainant made a complaint before this Forum. The insurer informed that the complainant submitted the documents on 05.12.2018. The insurer further confirmed that they have now paid the claim on 10.02.2021 as per TPA’s Assessment for Rs.19712/-. As per records, the complainant has made the petition for payment of Rs.19800/- plus interest at 8%. 22. The attention of the complainant and the Insurer is hereby invited to the following provisions of Insurance Ombudsman Rule,2017: - a. According to Rule 17(6) of Insurance Ombudsman Rules,2017, the Insurer shall comply with the award within 30 days of the receipt of the award and shall intimate the compliance of the same to the Ombudsman, and b. As per Rule 17(8) of the said rules, the award of Insurance Ombudsman shall be binding on the Insurers. Dated at Bhubaneswar on the 18th day of March, 2020 INSURANCE OMBUDSMAN

FOR THE STATE OF ODISHA PROCEEDINGS BEFORE


AWARD


both the parties during the course of hearing, the forum finds that the insurer

inordinately delayed settlement of the claim in spite of repeated requests made by the

complainant. They have settled the claim now on 10.02.2021, for which the TPA had

assessed on 22.12.2017. It is found that the insurer has paid Rs.19712/- without any

reason for such delay. Therefore, the insurer is directed to pay the penal interest in

accordance with the provisions under IRDAI (protection of policyholders’ interests)

Regulations, 2017 and confirm this office.

Accordingly, the complaint is allowed.


CASE OF Mr. Kartikeswar Sahoo Vrs. The Oriental Insurance Co. Ltd COMPLAINT REF: NO: BHU-H-050-2021-0133



Mr. Kartikeswar Sahoo Plot No. 145/1892, Lane-4, Jagannath Marg, Ananta Vihar Pokhariput. Bhubaneswar-751020. Mobile No. 9437607148


124500/48/2020/3052. Group Health Insurance Policy 01/10/2019 to 30/09/2020 Date of admission 05/05/2020 D.O.D 07/05/2020


Mrs. Swapnashree Sahoo Mr. Kartikeswar Sahoo

4. Name of the insurer The Oriental Insurance Co. Ltd

5. Date of Repudiation Not mentioned in the repudiation letter. Beyond the scope of the policy 6. Reason for repudiation


24/12/2020


9. Amount of Claim Rs. 85,626/-


11. Amount of relief sought Rs 99,617/-(claim amount 85,626+interest+comp. for harassment)


13(1)b



a) For the Complainant Self through telephone

b) For the insurer Mrs. S Sawant, Executive through telephone



17. a. Brief Facts of the Case/Cause of Complaint: - The Complainant & his family are covered under policy No. 124500/48/2020/3052 for the period from 01/10/2019 to 30/09/2020 having floater sum insured of Rs.10,00,000/-. His spouse Mrs. Swapnashree Sahoo was hospitalised in Sparsh Hospital, Bhubaneswar on 05/05/2020 and was discharged on 07/05/2020. As per Discharge summary her final diagnosis was AV FORMATION OF UTERINE ARTERY, MOLAR PREGNANCY. He lodged a claim for reimbursement of hospital expenses which was repudiated by the Insurer on the ground, ‘those insured persons who are already having two or more living children will not be eligible for this benefit’. Being aggrieved with repudiation; the complainant made an appeal before this forum for redressal. b. The insurer in their self-contained note admitted the issuance of the above policy. Earlier above claim was repudiated under clause 3.21 of the policy as it was observed that patient is already having 2 living children. However, claim file was reviewed again by senior medical team of Mediassist TPA and they observed, the ICPs have been scrutinized and found that she had symptoms of bleeding intermittently PV for 1 month but she was hemodynamically stable on

admission. Operation theatre note shows a growth in the intrauterine cavity 3X3 cms in size RPOC/Molar pregnancy. HPE Report confirming the RPOC/Molar pregnancy should be available but could not be traced. Lap Hysterectomy and B/L Salpingectomy was undergone for the AV malformation of the uterine artery which was diagnosed earlier by transvaginal sonography and CT Angiography. Both these reports should also be procured. Thus, expenses relating to Lap Hysterectomy may be considered under SI limit. In view of the above, claim has been reprocessed and found to be admissible for Rs.61,736/- as against claimed amount of Rs.85,626/-. They have informed the complainant about admissible claim amount and requested him for his consent. 18. a. Complainant’s Argument: Without going into medical investigation reports and operation theatre notes their team has drawn the conclusion that it is a maternity claim for third baby. It is clearly mentioned in the investigation reports by panel of qualified doctors from AIIMS, and SPARSH hospital that there was an AVM (Artery-Vain Malformation). Since it was bleeding continuously the doctor advised for removal of Uterus. Accordingly, the patient was hospitalised and undergone Advanced Laparoscopic Surgery. b. Insurer’s Argument: - They have reviewed the claim again and assessed for Rs. 61,736/- and intimated to the complainant accordingly. 19. Reason for Registration of Complaint: Scope of the Insurance Ombudsman Rules, 2017 20. The following documents are placed in the file.


21. Result of hearing with both parties (Observations & Conclusion): - This Forum has carefully gone through all the documents and papers relating the complaint and heard both the parties. The complainant stated that the insurer did not cooperate and did not settle the claim in spite of various telephone calls and e-mail correspondences. It is only after the case is filed before this office; the insurer offered settlement. But till yesterday the insurer was asking for some documents though all documents have already been submitted many a times. The complainant informed that the insurer asked to submit xerox copies of bills due to Covid-19 and therefore he submitted xerox copies. The insurer informed that they have given the assessment sheet to the complainant for settlement of the claim for Rs.61,736/-. But the complainant stated that the insurer has agreed to review the assessment once again and therefore they have referred the case to the TPA. The complainant submitted copy of the assessment given by the insurer where it says “bill not found for Rs.21612/-.”

AWARD


both the parties during the course of hearing, the forum finds that the insurer came into

action only after the complainant filed a case before this Forum for redressal, which was

after almost 10 months of the hospitalisation. The insurer now offered settlement for

Rs.61,736/- but learnt that they have again referred the matter to the TPA for review as

there is a discrepancy of bills for Rs. 21,612/-. Considering the delay in settlement of the

claim and in absence of the final assessment as yet, the Forum decides to consider the full

claim after deduction of reasonably 5% towards non-payable items and to pay penal

interest for the delay. Therefore, the insurer is directed to pay the complainant Rs.

81,345/- towards settlement of the claim (including pre and post hospitalisation claim)

plus penal interest in accordance with the IRDAI (Protection of Policyholders’ interests)

22. The attention of the complainant and the Insurer is hereby invited to the following provisions of Insurance Ombudsman Rule,2017:

a. According to Rule 17(6) of Insurance Ombudsman Rules,2017, the Insurer shall comply with the award within 30 days of the receipt of the award and shall intimate the compliance of the same to the Ombudsman. b. As per Rule 17(8) of the said rules, the award of Insurance Ombudsman shall be binding on the Insurers.

Dated at Bhubaneswar on the 22nd day of March, 2021 INSURANCE OMBUDSMAN FOR THE STATE OF ODISHA



CASE OF Mr. Pradipta Kumar Routray Vrs. Reliance General Insurance Co. Ltd



Mr. Pradipta Kumar Routray Flat No. 308 B, Ideal Plaza, Phase-VII, Tulasi Vihar Complex, Bhubaneswar-751021. Mobile No. 9437227475

2 Policy No: Type of Policy Duration of policy/Policy

240291928451000020. RGI-BOI Swasthya Bima Policy 28/03/2019 to 27/03/2020 Date of admission 30/01/2020 D.O.D 09/02/2020

period


Mr. Pradipta Kumar Routray Mr Pradipta Kumar Routray

4. Name of the insurer Reliance General Insurance Co. Ltd

5. Date of Repudiation 01/02/2020 Non-disclosure of pre-existing disease. 6. Reason for repudiation


21/01/2021




11. Amount of relief sought Rs 3,61,028


13(1)b



a) For the Complainant Self through personal appearance

b) For the insurer Mr. Tribikram Patnaik, Executive (personal appearance)



17. a. Brief Facts of the Case/Cause of Complaint: - The complainant Mr. Pradipta Kumar Routray is covered under policy No. 240291928451000020 for the period from 28/03/2019 to 27/03/2020 having floater sum insured of Rs.5,00,000/-. He was admitted in CARE Hospital, Bhubaneswar on 30/01/2020 with complaints of SOB, Fever, Nausea and was discharged on 09/02/2020. He lodged a claim for reimbursement of hospital expenses which was repudiated by the insurer on the ground of non-disclosure of material information. Being aggrieved, the complainant made an appeal before this forum for redressal. b. The insurer in their self-contained note admitted issuance of the above policy. The said policy is subject to policy terms and conditions. As per policy terms and conditions, Clause 5- Disclosure to Information Norm, it is clearly stipulated that in the event of mis-representation or non-disclosure of material facts, the policy shall be void. The complainant submitted a claim with respect to insurance coverage under the aforesaid policy vide Claim No. 201200053816. The subject claim lodged by the complainant was thoroughly scrutinized on the basis of details and documents provided by the complainant. After perusal of documents, more particularly the Questionnaire submitted by the complainant to the Insurance Company, it is observed by the Insurance company that the complainant is a known case of Hypertension and Diabetes Mellitus since 2015 on regular treatment but same was not disclosed by the complainant in the proposal copy at the time of policy inception and thus the claim is not covered as per policy terms and conditions. The said policy was sourced through Bank of India and person submitting the proposal has to provide the critical information of his pre-existing disease and conditions as there would be an option available to insurance company not to underwrite the policy. This case was of Diastolic

with LRTI, Type 2 DM and Hypertension and the complainant underwent treatment for hypertension as well during the course of hospitalisation. In the said case the condition of hypertension and diabetes is a declining risk and if the proposer would have declared the same, the company would have declined the policy. Since the complainant has not disclosed his past medical history at the time of policy inception, they repudiated the claim. 18. a. Complainant’s Argument: The plea of insurance company is contrary to the recorded position of the policy. Before inception of the policy the authorities of Reliance General Insurance Co. Ltd had verified the antecedents about his health and found no such medical defect in him, and on record, i.e. on the body of the policy it is mentioned by the authority of Reliance General Insurance Co. Ltd that ‘No Pre-existing disease” Insurer’s Argument: - The company has rightly repudiated the said claim as per the terms and conditions of the policy. 19. Reason for Registration of Complaint: Scope of the Insurance Ombudsman Rules, 2017 20. The following documents are placed in the file.


21. Result of hearing with both parties (Observations & Conclusion): - This Forum has carefully gone through all the documents and papers relating the complaint and heard both the parties. The insurer stated that the patient is a known case of HTN and he was diagnosed for LRTI, Diastolic Dysfunction, T2DM, HTN, but the complainant did not disclose the pre-existing conditions at the time of taking the policy, therefore the claim is not tenable under the condition of non-disclosure of facts. The complainant stated that he has been renewing the policy since 25.01.2011 with National Insurance Co ltd through his Banker under Group Insurance. Because the bank changed to Reliance General Insurance Co Ltd in 2019, he shifted to the present insurer for the period from 28.03.2019 to 27.03.2020. The present insurer has the waiting period of 36 months for pre-existing disease. The Forum, for the purpose of 36 months waiting period, has examined the following policy periods and found to be renewed i.e. 21.03.2016 to 20.03.2017 (SIV Rs.2.00 lac), 21.03.2017 to 20.03.2018 (SIV Rs.2.00 lac), 21.03.2018 to 20.03.2019 (SIV Rs.2.00 lac) renewed with National Insurance Co Ltd. Then it is shifted to Reliance General Insurance Co ltd for the period from 28.03.2019 to 27.03.2020 (SIV Rs.5.00 lac). It is found that the sum insured has been increased during the current policy from Rs.2.00 lac to Rs.5.00 lac.

AWARD


both the parties during the course of hearing, the forum finds that the complainant

has continuously renewed the policy with National Insurance Co Ltd, but when

shifted to Reliance General Insurance Co Ltd, there was a gap of 7 days. But he has

renewed well within the grace period of 15 days. The Forum finds that the

complainant has continued renewal, for at-least last 36 months (with National) prior

to the present policy. This means the 36-month exclusion clause for pre-existing

conditions is not applicable to the complainant for the claims arising under the

present policy. Therefore, the claim is admissible. However, the 36-month exclusion

shall be applicable to the increased sum insured. As far as the maximum eligible



Dated at Bhubaneswar on the 22nd day of March, 2021 INSURANCE OMBUDSMAN

FOR THE STATE OF ODISHA PROCEEDINGS BEFORE



CASE OF Mr. Rajendra Kumar Mohapatra Vrs. The Oriental Insurance Co. Ltd COMPLAINT REF: NO: BHU-H-050-2021-0142



Mr. Rajendra Kumar Mohapatra Police Line Road, Duttatota, Infront of Wireless Office Puri-752001. Odisha. Mobile No. 9437353350


345300/48/2021/141 Group Health Insurance Policy 17/04/2020 to 16/04/2021 (Inception 17/04/2019) Date of admission 23/05/2020 D.O.D 26/05/2020


Mr. Rajendra Kumar Mohapatra Mr. Rajendra Kumar Mohapatra

4. Name of the insurer The Oriental Insurance Co. Ltd

5. Date of Repudiation 09/11/2020 Hospitalised during waiting period 6. Reason for repudiation


11/01/2021




11. Amount of relief sought Rs 2,41,202/-


13(1)b



a) For the Complainant Self through personal appearance

b) For the insurer Mr. Amaresh Rout, DM through telephone



17. a. Brief Facts of the Case/Cause of Complaint: - The Complainant Mr Rajendra Kumar Mohapatra is covered under Policy No. 345300/48/2021/141 for the period from 17/04/2020 to 16/04/2021 having sum insured of Rs.3,00,000/-. He was hospitalised on 23/05/2020 with complaints of Acute ASMI, CAD & Plan for PTCA + Stenting and was discharged on 26/05/2020. Then he lodged a claim for reimbursement of hospital expenses which was repudiated on the ground, treatment done during waiting period of 24 months. Being aggrieved with repudiation, the complainant made an appeal before this forum for redressal. b. The insurer in their self-contained note admitted issuance of the above policy. The complainant lodged a reimbursement claim. On scrutinization of submitted documents it had been observed that this 56-year-old male patient was admitted with complaints of Acute ASMI, CAD & Plan for PTCA + Stenting. Patient had been found to have been suffering from Hypertension- for 1 year as evident from the Emergency case sheet and Discharge summary. Since the policy inception date is 17/04/2019, this is 2nd year running policy & the member had been suffering from HTN for 1 year, there is 2 years waiting period as per Policy terms and conditions, hence the claim is considered for repudiation as per clause No.4.2 of sl. No. XVII. 18. a. Complainant’s Argument: Dr. Mahendra Tripathy opines the current MI is mostly likely not related to HTN, as the duration of HTN is short and stage 1. b. Insurer’s Argument: - The treatment undertaken within the waiting period of 24 months which is not admissible as per Policy condition no.4.2 sl. No. XVII. 19. Reason for Registration of Complaint: Scope of the Insurance Ombudsman Rules, 2017 20. The following documents are placed in the file.


21. Result of hearing with both parties (Observations & Conclusion): - This Forum has carefully gone through all the documents and papers relating the complaint and heard both the parties. The insurer stated that the patient is a known case of HTN for one year as per Discharge Summary. This is also specified in Emergency case sheet. They further stated that HTN falls under 2-year exclusion clause and hence the claim is not payable. The complainant stated that he was never a HTN patient. The reports are wrongly written; therefore, the treating doctor has given a certificate to the effect stating that “the current MI is most likely not related to HTN as the duration of HTN is short and stage I”.



Dated at Bhubaneswar on the 22nd day of March, 2021 INSURANCE OMBUDSMAN




CASE OF Mrs. Nurjahan Begum Vrs. SBI General Insurance Co. Ltd



Mrs. Nurjahan Begum, Reader Choudwar College, Choudwar, PO; Kapaleswar Dist: Cuttack-754071. Mobile No. 9692872692

2 Policy No: Type of Policy

0000000006306040-03, Group Health Insurance Policy

AWARD


both the parties during the course of hearing, the forum finds that the case may not

be necessarily related to HTN. Moreover, the treating doctor certified vide Patient

Demographic Details dated 05.10.2020 that the treatment is most likely not related

to HTN. The complainant admitted that he has never suffered from HTN nor has

taken any medicine earlier. Considering the above facts, the Forum concludes that

the claim is payable and therefore, the insurer is directed to pay the complainant Rs.

2,25,199/- (Bill amount of Rs. 237052/- with a reasonable deduction 5% towards non-

payable items) towards full and final settlement of the claim.

Accordingly, the complaint is allowed.


31/03/2020 to 30/03/2021 (inception from 31/03/2017) Date of admission 02/09/2020 D.O.D 11/09/2020


Mr. SK Nasiruddin Mr. SK Nasiruddin

4. Name of the insurer SBI General Insurance Co. Ltd

5. Date of Repudiation 25/10/2020 Hospitalised within waiting period of 48 months 6. Reason for repudiation


18/01/2021




11. Amount of relief sought Rs 83.631/-


13(1)b



a) For the Complainant Self through Personal appearance

b) For the insurer Ms. Chynica Modi, Legal Officer Through VC



17. a. Brief Facts of the Case/Cause of Complaint: - The Complainant (Policyholder/insured) & her are spouse covered under policy No. 0000000006306040-03 for the period from 31/03/2020 to 30/03/2021 having floater sum insured of Rs.1,00,000/-. Her spouse Mr. SK. Nasiruddin was hospitalised in Sriram Medicare Centre, Cuttack on 02/09/2020 for treatment of CVA Left hemiparesis and was discharged on 11/09/2020. Then she lodged a claim for reimbursement of hospital expenses which was repudiated on the ground pre-existing disease and hospitalised within waiting period of 48 months. Being aggrieved with repudiation the complainant made an appeal before this forum for redressal. b. The insurer in their self-contained note admitted the issuance of above policy. The policyholder/insured Mr. SK. Nasiruddin was hospitalised in Sriram Hospital, Zobra, Cuttack from 02/09/2020 to 11/09/2020 for treatment of Cerebrovascular accident, left hemiparesis (right thalamic, temporo-occipital subacute infract with haemorrhagic transformation). Two consecutive claims i.e. a reimbursement claim bearing No. 101409216/200320040161-01 and thereafter a post-hospitalisation reimbursement claim no. 101859188/200320040161-02 was registered on behalf of the insured under the effective policy bearing no. 0000000006306040-03 towards the expenses related to aforesaid hospitalisation. The insurer states that the claim file was assessed by the TPA to complete the process of evaluation of authenticity and eligibility of the claim. Based on the medical documents received from the hospital and other documents available on record, it was deduced that, during the investigation, the treating doctor Dr. Deepak Das vide his declaration dated 28/09/2020, stated that the insured had a past history of diabetes mellitus and hypertension for 15 years, and the haemorrhage in the right temporo-occipital lobe is due to prolonged hypertension. Further, the OPD Ticket dated 02/09/2020, also confirms that the insured had hypertension since 15 years, and was taking medicine for the same.

Further, Dr. Sanat Mishra, in his written statement dated 22/09/2020, also stated that the insured had suffered from a cerebrovascular accident in January 2020 and recurrence of the cerebrovascular accident is due to high blood pressure. Thus, hypertension and diabetes mellitus, which were pre-existing in nature, is a pre-cursor of the present ailment. Hence, the submitted medical documents, irrevocably established that much prior to inception of the policy, the insured had been suffering from signs and symptoms which are directly attributable to the currently diagnosed disease. Hence considering the past history of stated ailment and details of present ailment/treatment, which are a likely sequel, the Company found the claimed hospitalisation/treatment to be beyond the scope of said policy as per policy exclusion clause no. 1. EXCLUSION CLAUSE NO. 1 Pre-existing Disease Exclusion: - Benefits will not be available for any condition, ailment or injury or related condition(s) for which insured has been diagnosed, received medical treatment, had signs and/or symptoms, prior to inception of insured person’s first group health policy, until 48 consecutive months have elapsed, after the date of inception of the first group health policy with SBI General. Furthermore, the complainant while contracting for said insurance policy in 2017, deliberately failed to disclose his illness history in the proposal form. In spite of the fact that proposal form had specific and individual checkbox for past history and ailments of the proposer. As per the subject policy, the conditions clearly state that the policy shall be void and all premium paid hereon shall be forfeited to the company in the event of misrepresentation, mis-description or non-disclosure of any material fact. 18. a. Complainant’s Argument: One of her relative had given wrong information to the doctor that the patient was a known case of Type-2 DM & on medication since last 15 years. But actually, he is taking medications for Type-2 DM since last 1 year. b. Insurer’s Argument: - The claim was not tenable and it was appropriately denied as per Exclusion Clause No.1. 19. Reason for Registration of Complaint: Scope of the Insurance Ombudsman Rules, 2017 20. The following documents are placed in the file.


21. Result of hearing with both parties (Observations & Conclusion): - This Forum has carefully gone through all the documents and papers relating the complaint and heard both the parties. It is found that the policy was 1st incepted on 31.03.2017. The claim was repudiated by the insurer under pre-existing exclusion clause stating the patient had HTN and T2DM for last 15 years and the same was not declared by the policyholder while taking the policy. The insurer stated that the treating doctor vide Declaration dated 28.09.2020, has clearly mentioned the duration of HTN to be since 15 years. The insurer further stated that the OPD ticket also records that the HTN and T2DM existing for 15 years. The complainant informed that the hospital, vide a note dated 11.11.2020, has mentioned that initially it was recorded to be 15 years as informed by one of the patient’s relatives, but it is for last 1 year as per their family members. The complainant informed that the patient did not have any such condition for last 15 years but for last 1 year and the claim should be paid.



Dated at Bhubaneswar on the 26th day of March, 2021 INSURANCE OMBUDSMAN FOR THE STATE OF ODISHA

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF TAMIL NADU & PUDUCHERRY (UNDER RULE NO: 16/17 OF THE INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN – Shri M Vasantha Krishna Case of Mrs Vijayasri Vs United India Insurance Company Limited

COMPLAINT REF: NO: CHN-H-051-2021-0389 Award No: IO/CHN/A/HI/0167/2020-2021

1. Name & Address of the Complainant Mrs Vijayasri 27/8, Brightons Road, II Street, Kannikapuram, Chennai – 600 012

2. Policy No. Type of Policy Duration of Policy/Policy Period Sum Insured (SI)

0217002819P11667155 Tailormade Group Health Policy 30.03.2020 to 29.03.2021 INR 4 lakhs (on floater basis)

3. Name of the Insured Name of the Policyholder/Proposer

Mr S D Sankarkumar Tech Mahindra Ltd.

4. Name of the Insurer United India Insurance Company Limited

AWARD


both the parties during the course of hearing, the forum finds that the patient fell

down as a result of HTN and further was admitted for treatment. There is a corelation

between HTN and falling down and thereby necessitating the treatment. It is found

that as per OPD ticket and the Declaration from the Treating doctor the patient had

HTN and T2DM for last 15 years. The Hospital note dated 11.11.2020, signed by Dr.

Dibyayoti Sahoo who was not a treating doctor, has not given any medical view

except narrating the statements of a relative and family members. Therefore, this is a

clear case of pre-existing disease, which is an exclusion under the policy. Therefore,

as per policy conditions, the claim is not payable and the complainant is not entitled

for benefits under the policy.

Accordingly, the complaint stands dismissed.

20. Brief Facts of the Case:

The complainant as an employee of Tech Mahindra Ltd has covered herself, her

spouse, son and her dependent parents in the Tailormade Group Mediclaim Policy

issued by the respondent insurer (RI) for the period 30.03.2020 to 29.03.2021 to her

employer.

As per the Discharge Summary of Aravind Eye Hospital, Chennai, the complainant’s

father Mr S D Sankarkumar who is covered under the policy was admitted on

10.09.2020 for the complaint of defective vision and was diagnosed as a case of PAC –

Primary Angle Closure, PACG – Primary Angle Closure Glaucoma, Status Post PI in the

right eye and Anophthalmos in the left eye. He was administered Intravitreal Injection

Accentrix in the right eye and was discharged on the same day.

The treating doctor issued a certificate stating that “the patient was diagnosed with

Proliferative Diabetic Retinopathy - RE for which patient was advised – RE Intravitreal

Accentrix Injection. It was given on 10.09.2020”.

5. Date of repudiation of the claim 03.11.2020

6. Reason for repudiation Under clause 2.29 of the policy


8. Nature of Complaint Rejection of claim

9. Date of receipt of Consent (Annexure VI A)

22.12.2020

10. Amount of Claim INR 21,133

11. Amount paid by the insurer, if any NIL

12. Amount of Monetary Loss (as per Annexure VI A)

INR 21,133

13. Amount of Relief sought (as per Annexure VI A)

INR 21,133

14. a. Date of request for Self-contained Note (SCN)

09.12.2020

14. b. Date of receipt of SCN 07.01.2021

15. Complaint registered under Rule No. 13(1) (b) of the Insurance Ombudsman Rules, 2017

16. Date of Hearing/Place By Video Conferencing (VC) on 23.02.2021


a) For the Complainant Ms Vijayasri

b) For the Insurer Ms Sneha / Dr Viswanath

18. Disposal of Complaint By Award


The hospital charged an amount of INR 19,750 for the procedure and a claim for INR

21,133 inclusive of related expenses was submitted to the RI. The RI rejected the claim

citing Clause 2.29 of the policy which reads as under.

Out-Patient Department – OPD Treatment is one in which the insured visits a

clinic/hospital or associated facility like a consultation room for a diagnosis and

treatment based on the advice of a medical practitioner. The insured is not admitted as

a day care or in-patient.

She represented to the RI to reconsider their decision to deny the claim. She submitted

to the RI that her father had undergone a daycare procedure and not an OPD treatment.

Further, she pointed out that a previous claim for the very same treatment in July 2020

had been settled by the RI. In response to her representation, the RI replied as under,

vide their letter dated 24.11.2020.

“On perusal of claim documents submitted, the patient got admitted on 10.09.2020 and

got discharged on the same day at ARAVIND EYE HOSPITAL and was diagnosed with

DEFECTIVE VISION so the patient has underwent administration of Intravitreal Injection

(Injection Accentrix) wherein a shot of Medicine is given into the eye. The period of

hospitalisation for cases involving administration of Intravitreal Injections is less than 24

hours. Further the terms and conditions of the specific Group Health Insurance policy

issued to you as esteemed corporate client under which the Insured member is covered

DOES NOT highlight administration of said injection under the list of Day Care

Treatments (clause no. 3.1). So the claims involving administration of Intravitreal

Injection are not payable as it does not require 24 hours hospitalisation and is not listed

under Day care treatments”.

Aggrieved by the reply of the insurer, the complainant has approached this Forum for

relief.

21 (a) Complainant’s Submission:

Her father was administered Injection Accentrix and the treatment was

performed as a daycare procedure on 10.09.2020.

The claim was rejected on the ground that the treatment is an out-patient

diagnosis service. However, the discharge summary and the certificate of the

treating doctor confirms that it is a daycare procedure.

She also submits that the RI had settled the claim for the same treatment

undergone by her father on 27.07.2020 in the same hospital. This proves that

the treatment is indeed a daycare procedure covered under the policy.

However, on her representing the matter, the TPA took the stand that the

administration of Injection Accentrix is not covered as it is not listed as a

daycare procedure in the policy and the previous claim was approved by

mistake.

Her representation to the Regional Office of the RI on the issue was not

responded to. She then raised a complaint on their grievance portal and

received a response. Since the reply was not satisfactory, she has approached

this Forum anticipating a favourable resolution.

21 (b) Insurer’s Submission:

The RI submitted their SCN dated 21.12.2020 and made the following averments.

On the basis of the online grievance raised by the complainant, the case was

referred to the RI’s panel doctor Dr Rupesh Avhale who has opined as under:

a) The patient underwent administration of an IV injection wherein a shot of

medicine is given in the eye.

b) Further, for the administration of the said injection, strict aseptic precautions

are required. If aseptic precautions are not adequately maintained, it may

lead to eye-related devastating complications like Endophthalmitis (infection

of the interior of the eye).

c) Hence, to ensure strict aseptic precautions, the intravitreal (IV) injection is

administered in an Ophthalmic Operation Theatre.

d) As a result, the said injection cannot be administered on OPD basis. Thus,

the ground invoked by the Third-party Administrator (TPA) for denial of the

claim is incorrect and inappropriate.

e) However, the period of hospitalization for cases involving the administration of

IV injections is less than 24 hours.

f) Further, the terms and conditions of the specific Group Health Insurance

Policy issued to our esteemed corporate client under which the insured

member is covered DOES NOT highlight administration of said injection

under the list of daycare treatments (Clause No. 3.1).

g) As per their Internal Circular No. HO HEALTH:043:16-17 dated 05.05.2016,

the claims involving administration of IV injection are not payable as it does

not require 24 hours hospitalization and is not listed under daycare treatment.

They have drawn the attention of the Forum to Clause 3.1 of the policy which

lists the specific treatments to which the time limit of a minimum period 24

consecutive hours of hospitalization is not applied and or any other

surgeries/procedures agreed to by the TPA/ the insurance company which

require less than 24 hours hospitalization and for which prior approval from TPA/

the insurance company is mandatory.

This condition will also not apply in case of stay in hospital of a duration less than

24 hours provided (a) The treatment is undertaken under General or Local

Anesthesia in a hospital/ daycare centre in less than 24 hours (b) due to

technological advancement and (c) which would have otherwise required

hospitalization of more than 24 hours.

Note: Procedure/Treatments usually done in the out-patient department are not

payable under the policy, even if converted as an in-patient in the hospital for

more than 24 hours or carried out in daycare centres.

The RI concluded that the subject treatment does not fall under the daycare

category as per the policy and the claim stands denied under Policy Exclusion

2.29. Hence, the claim has been repudiated as per clauses, terms and conditions

of the policy.

In view of the same, the RI request the Forum to uphold their decision to reject

the claim.

22. Reason for Registration of the Complaint:

The complaint is registered under Rule No. 13(1) (b) of the Insurance Ombudsman

Rules, 2017, which deals with “Any partial or total repudiation of claims by the Life

Insurer, General Insurer or the Health Insurer”.

23. Documents placed before the Forum:

Written Complaint dated 09.12.2020 to the Insurance Ombudsman

Claim repudiation letter of the RI undated

Complainant’s representation dated 20.11.2020 to the RI

RI’s response dated 24.11.2020 to the Complainant

Consent (Annexure VI A) submitted by the Complainant

Self-contained Note (SCN) of Insurer dated 21.12.2020

Copy of Policy with terms and conditions

Claim form Part B dated 10.09.2020

Discharge summary/Medical Report/Bills of Aravind Eye Hospital

Complainant’s mail correspondence with the Insurer and TPA

Certificate of Dr R Anand of Aravind Eye Hospital, Chennai dated 16.10.2020

RI’s internal circular HO:HEALTH:043:16-17 dated 05.05.2016

Settlement letters of the TPA dated 27.08.2020 and 11.12.2020

24. Result of hearing (Observations & Conclusion)

Because of the prevalent COVID 19 pandemic situation, the hearing was

conducted by VC on 23.02.2021, with the consent and participation of both the

complainant and the RI. Ms Vijayasri, the complainant, Ms Sneha, RI’s

representative and Dr Viswanath, representative of the TPA attended the

hearing.

During the hearing, the complainant submitted that her father was suffering from

defective vision and the doctor at Aravind Eye Hospital suggested the

administration of intravitreal injection Accentrix thrice. The first injection was

given on July 27 2020, followed by the second and third on 10.09.2020 and

16.10.2020 respectively. The insurer settled the claim for the expenditure

incurred for the first and the third injections and inexplicably disallowed the claim

for the second injection on 10.09.2020 on the ground that the treatment could

have been managed on an OPD basis. She also submitted that intravitreal

injection is the only treatment option for her father’s ailment and it is unfair on the

part of the RI to disallow the same, especially when a previous and a subsequent

claim were approved for the same treatment.

The repudiation of the claim by the RI on the ground that the treatment is an

OPD treatment is deeply problematic as their own panel doctor has clarified that

it is a daycare procedure and not an OPD procedure. Moreover, the RI invoked

a definition clause (clause no. 2.29) to deny the claim, although they termed it as

an exclusion clause in the letter of repudiation. Hence, the repudiation is not only

on an incorrect ground but also legally deficient, in the considered opinion of the

Forum. It was only in response to the appeal made by the complainant that the

RI modified their stand for repudiating the claim and informed her that the

procedure undergone was not a listed daycare procedure.

While the argument of the RI and the TPA that the claim for the first injection was

admitted by oversight is understandable, their action of settling the claim for the

third injection after rejecting the second claim (subject claim) for the same

procedure cannot be explained away in the same fashion. It reveals an

inconsistent and whimsical approach to the processing and settlement of claims

by the TPA with no control being exercised by the RI.

Coming to the issue of whether the procedure underwent is a daycare procedure

or not, the RI is right in asserting that the same is not a listed daycare procedure in

the policy. However, it is necessary to examine whether the procedure satisfies the

parameters of a daycare procedure as laid out in clauses 2.10 and 3.1 of the

policy. As per these clauses, daycare treatment refers to medical treatment and or

surgical procedure which is -

i. Undertaken under General or Local Anaesthesia in a hospital/daycare centre in

less than 24 hours because of technological advancement and

ii. which would have otherwise required hospitalisation of more than 24 hours.

Treatment normally taken on an out-patient basis is not included in the scope of

this definition (even if converted to in-patient or daycare treatment)

The injection was administered under local anaesthesia and as pointed out by

the complainant it is the only treatment available for the condition in question.

Therefore, it has to be considered an advanced procedure. It is also relevant to

note that IRDAI, the Insurance Regulator has also recognised the treatment as

advanced and advised insurers not to exclude intravitreal injections under

policies issued on or after 01.10.2020. In the opinion of the Forum, the

requirement of technological advancement is, therefore, met. The stipulation that

but for the availability of the advanced procedure, the treatment would have

otherwise required hospitalisation of more than 24 hours is redundant,

considering that there is no other treatment available.

The RI also argued that such daycare procedures as are not listed in the policy

would require prior approval of the Company and the TPA. However, there

appears to be no such proviso in the policy issued, either as part of the standard

terms and conditions or in the special terms and conditions attached thereto.

Even assuming such a condition is applicable, the complainant was entitled to

presume that the approval exists, given the settlement of the first claim by the

TPA.

The RI also relied upon the circular issued by their HO to argue that intravitreal

injections are not admissible under the policy. But such internal instructions are

not binding on the policyholders unless suitably incorporated in the policy

wording.

For all the above reasons, the Forum concludes that the rejection of the claim by

the RI is not justified.

25. The attention of the Respondent Insurer is hereby invited to the following

provisions of the Insurance Ombudsman Rules, 2017:

a) According to Rule 17(6) of the Insurance Ombudsman Rules, 2017, the insurer

shall comply with the award within thirty days of the receipt of the award and

intimate compliance of the same to the Ombudsman.

b) According to Rule 17(7) of the Insurance Ombudsman Rules, 2017, the

complainant shall be entitled to such interest at a rate per annum as specified in

the regulations, framed under the Insurance Regulatory and Development

Authority of India Act, 1999, from the date the claim ought to have been settled

under the regulations, till the date of payment of the amount awarded by the

Ombudsman.

c) According to Rule 17(8) of the Insurance Ombudsman Rules, 2017, the award of

the Insurance Ombudsman shall be binding on the insurers.

Dated at Chennai on this 11th day of March 2021.

AWARD

Taking into account the facts & circumstances of the case and the submissions

made by both the parties, the Forum hereby directs the respondent insurer to

settle the claim of the complainant for INR 21,133 along with interest as provided

under Rule 17(7) of the Insurance Ombudsman Rules, 2017, subject to the other

terms and conditions of the Policy.

Thus, the complaint is allowed.

(M Vasantha Krishna)

INSURANCE OMBUDSMAN

FOR THE STATE OF TAMIL NADU AND PUDUCHERRY

PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATE OF TAMILNADU & PUDUCHERRY

(UNDER RULE NO: 17(1) of the INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN – SHRI M VASANTHA KRISHNA

CASE OF Mr D Jeron Raj Vs Bajaj Allianz General Insurance Co. Ltd

COMPLAINT REF: NO: CHN-H-005-2021-0419

Award No: IO/CHN/A/HI/0176/2020-2021



Mr D Jeron Raj 6/20 A-A1, Noah’s Ark, Mela Soorankudy, Nagercoil 629004


OG-19-2001-8403-00000277 Group Mediclaim Policy 01/11/2018-31/10/2019


Mr J T Nitesh Sharan Bajaj Allianz Life Insurance Co. Ltd A/c Mr D Jeron Raj

4. Name of the insurer Bajaj Allianz General Insurance Co. Ltd

5. Date of repudiation of the claim 29/11/2019

6. Reason for repudiation No active line of treatment or investigative procedure

7. Date of receipt of the Complaint 18/12/2020

8. Nature of complaint Non-settlement of the claim

9. Date of receipt of consent Annexure VIA)

07/01/2021

10. Amount of Claim INR 1,25,561

11.

Amount of Monetary Loss (as per Annexure VIA)

INR 1,25,957

12. Amount paid by the Insurer, if any Nil

13. Amount of Relief sought (as per Annexure VIA)

INR 1,25,957

14.a. Date of request for Self-contained Note (SCN)

22/12/2020

14.b. Date of receipt of SCN 10/02/2021


Rule 13(1)(b) of the Insurance Ombudsman Rules, 2017

16. Date of hearing/place By Video Conferencing (VC) on 19/02/2021


For the Complainant Mr D Jeron Raj

For the insurer Mr Mohamed Bilal Ali & Dr Ravindra Shingate


19. Date of Award/Order 25/03/2021

The Complainant’s son who is covered under the respondent insurer (RI)’s

Group Mediclaim Policy issued to Bajaj Allianz Life Insurance Company Ltd for

the period from 01/11/2018 to 31/10/2019 was admitted to Christian Medical

College (CMC), Vellore on 03/06/2019 for follow- up treatment of Congenital

Muscular Dystrophy (CMD), Spastic Diplegia (Cerebral Palsy), Crouch Gait for

which he had earlier undergone B/L DFEO/ Patellar Tendon Advancement, CLO,

Vulpius and left foot 1st MTP Arthrodesis under General Anaesthesia.

A cashless request raised for the above hospitalization was denied by the RI by

invoking exclusion clause C 10 of the policy on the ground that there was no

such active treatment/ investigation being carried out which requires

hospitalization. The reimbursement claim preferred was also repudiated on the

same ground.

Aggrieved by the repudiation of the claim, the complainant represented to the RI

to reconsider their decision by submitting a supportive document from the

hospital. But the RI did not revise their earlier stand of repudiation.

Therefore, the complainant has approached this Forum for relief.

21 a. Complainant’s submission:

The complainant’s son is a person with Cerebral Palsy & Spastic Diplegia. Earlier

he had undergone surgical correction for lower limb deformities and was

discharged from CMC on 25/04/2019.

The RI had approved the hospitalization expenses in respect of the surgery

previously undergone besides the post-hospitalization expenses incurred up to

31/05/2019.

As per the treatment plan, the complainant’s son was admitted to the Physical

Medicine & Rehabilitation (PMR) Unit 1 of the CMC on 03/06/2019 and was

discharged on 26/07/2019 after 54 days of hospitalization.

Since the cashless request raised was denied, a reimbursement claim was

preferred. But the RI repudiated the reimbursement claim also on the ground that

there was no active line of treatment.

The complainant submitted a certificate dated 12/12/2019 from the PMR

Department of the Hospital confirming that the patient was on appropriate pain

management and spasticity medication during the 6 weeks of his admission. He

was on regular occupational and physiotherapy for 4 to 6 hours per day which

enabled him to progress in his level of functioning from being bedridden to being

able to walk with bilateral knee ankle foot orthosis, initially parallel bars, then a

walker and then with elbow crutches. Despite this, the RI did not reconsider their

decision to reject the claim.

Post-hospitalization expenses are allowed for a period of 60 days from the date

of discharge of the previous hospitalization and hence the expenses incurred up

to 24/06/2019 are payable. But the RI failed to pay the same.

In view of the above, Forum’s intervention is requested for settlement of the

complainant’s claim of INR 1,25,957.

b. Insurer’s contention:

The complainant’s claim is in respect of his son’s admission to CMC Hospital

from 3rd June 2019, post-surgery, with the objective to improve his ROM of

bilateral knee, ankle, to improve his hand functions, walking with walker/ elbow

crutches, knee gaiters and Ankle Foot Orthosis and for the purpose of

physiotherapy and rehabilitation.

The cashless request raised for the above hospitalization was denied under

Exclusion clause C10 of the policy which reads as under

“The Company shall not be liable to make any payment under this Policy in

respect of any expenses whatsoever incurred by any Insured Person in

connection with or in respect of Charges incurred at Hospital or Nursing Home

primarily for diagnostic, X-ray or laboratory examinations not consistent with Or

incidental to the diagnosis and treatment of the positive existence or presence of

any ailment, sickness or injury, for which confinement is required at a

Hospital/Nursing Home.”

The reimbursement claim preferred was also repudiated under the same clause

since there was no such treatment being administered (active line of treatment)

or any such investigative procedure being performed which warranted

hospitalization.

Insured was hospitalized as an in-patient for physiotherapy and rehabilitation.

He did not require inpatient hospitalization only for physiotherapy and

rehabilitation, as this treatment can be given on an out-patient (OPD) basis.

Hence the inpatient hospitalization is not justified.

The main objective of the insurance contract is to indemnify the insured for the

damages caused by sudden perils or accident, sickness, ailment or injury which

occurs without any premeditation and without the knowledge of the insured.

Hence, the said post-surgery rehabilitation therapy undergone by the insured

does not come under the definition of accident/ illness/ injury/ailment as per the

policy wordings and definitions and any expenses incurred for the same will not

be indemnified by the Company.

The rehabilitation treatment comes under the category of ancillary treatment of

the complainant’s son to improve his physical abilities and is not proximately

connected to the main disease/injury/ailment. Hence, the same is rejected under

the policy terms and conditions.

The complainant himself admitted that his son was suffering from Spastic

Diplegia & Cerebral Palsy. Since the condition was identified when he was only

18 months old, it is a congenital anomaly. As it is a congenital internal deformity

all inpatient hospitalization for the same is admissible.

The import of clause C 10 is that the insurance company will cover only the

hospitalization expenses for necessary treatment and not for physiotherapy,

rehabilitation and exercises for which hospitalization is not required or not

needed and the same can be availed on an out-patient basis. Hence, the

expenditure incurred is not covered under the policy.

In the above circumstances, the RI humbly prays that the Forum may be pleased

to dismiss the complaint in the interest of justice.

22. Reason for Registration of Complaint:

The complaint is registered under Rule13 (1) (b) of the Insurance Ombudsman Rules,

2017, which deals with “Any partial or total repudiation of claims by the life insurer,

General insurer or the health insurer”.


Complaint dated 14/12/2020 to the Insurance Ombudsman

Denial of cashless facility dated 10/06/2019.

Claim repudiation letter dated 29/11/2019

Complainant’s grievance representation dated 12/12/2019 to the RI

RI’s reply dated 26/12/2019 to the complainant


Self-contained Note (SCN) of the RI

Copy of policy with terms & conditions and benefit chart

Claim form dated 21/09/2019

Discharge summary and invoice of CMC, Vellore

Certificate dated 12/12/2019 of PMR Department of CMC, Vellore.


1. Given the prevalent COVID 19 pandemic situation, the hearing was conducted

through VC on 19/02/2021, with the consent and participation of both the

complainant and the insurer.

2. The Forum records its displeasure over the delay in submission of the SCN by

the insurer.

3. The subject matter of the dispute is the RI’s repudiation of the complainant’s

claim in respect of his son who had undergone physiotherapy for 4-6 hours per

day, 6 days a week, besides appropriate pain management and spasticity

medication, on the ground that there was no active line of treatment during the

hospitalization.

4. The RI’s SCN is replete with contradictions and misinterpretation of the policy

terms. On one hand, they have averred that the treatment underwent is in

respect of an internal congenital anomaly and hence admissible and on the other

hand, they have repudiated the claim. Their interpretation of clause C 10 that the

same excludes hospitalization for physiotherapy is erroneous. The clause only

excludes hospitalization which is primarily for diagnosis and investigation and is

not followed by treatment for which hospitalization is necessary. In the instant

case, the hospitalization was not for diagnosis but planned physiotherapy and

rehabilitation following surgery. The argument of the RI that such treatment is not

proximately connected to the main disease is perverse, when they have

themselves admitted it is a post-surgery procedure. The RI’s contention that the

main objective of the insurance contract is to indemnify the insured for the

damages caused by accident, sickness, ailment or injury which occurs without

any premeditation and without the knowledge of the insured and hence the

planned physiotherapy is not covered has no basis whatsoever, either in the

policy terms & conditions or in the principles of insurance. The RI have not

understood the fact that the element of fortuity shall apply to the illness and not to

the treatment. Hence, their argument that a planned treatment as in the present

case is not covered is illogical, to say the least. The rejection of the claim under

exclusion clause C 10 is neither justified nor tenable.

5. The RI’s stand that there was no active line of treatment is amply rebutted by the

certificate dated 12/12/2019 from PMR Department of CMC, Vellore, wherein it

has been specifically stated that the patient was on appropriate pain

management and spasticity medication during the 6 weeks period of admission.

He was on regular occupational and physiotherapy for 4 to 6 hours per day and 6

days a week during that period.

6. As regards the contention of the RI that the treatment did not warrant

hospitalization and could have been provided on an out-patient basis, the Forum

is of the opinion that the treating doctors and the hospital were best placed to

decide whether the treatment should be rendered through admission in the

hospital or the out-patient department. In any case, there is no such clause in

the policy issued by the RI which excludes conversion of out-patient treatment

into hospitalization.

AWARD

Taking into account the facts & circumstances of the case and the

submissions made by both parties, the Forum concludes that the repudiation

of the claim by the respondent insurer is not in order. The insurer is therefore

directed to settle the complainant’s claim of INR 1,25,957, subject to terms

and conditions of the policy, along with interest as defined under Rule 17 (7)

of the Insurance Ombudsman Rules, 2017.

Thus the complaint is allowed

25. The attention of the Insurer is hereby invited to the following provisions of the

Insurance Ombudsman Rules, 2017:

a) According to Rule 17(6) of the Insurance Ombudsman Rules, 2017, the insurer shall comply with the

award within thirty days of the receipt of the award and intimate compliance of the same to the

Ombudsman.

b) According to Rule 17(7) of the Insurance Ombudsman Rules, 2017, the complainant shall be entitled

to such interest at a rate per annum as specified in the regulations, framed under the Insurance

Regulatory and Development Authority of India Act, 1999, from the date the claim ought to have been

settled under the regulations, till the date of payment of the amount awarded by the Ombudsman.

c) According to Rule 17(8) of the Insurance Ombudsman Rules, 2017, the award of the Insurance

Ombudsman shall be binding on the insurers.



INSURANCE OMBUDSMAN


PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATE OF TAMILNADU & PUDUCHERRY

(UNDER RULE NO: 17(1) of the INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN – SHRI M VASANTHA KRISHNA

CASE OF Mr A Ponnuraj Vs United India Insurance Company Ltd

COMPLAINT REF: NO: CHN-H-051-2021-0386

Award No: IO/CHN/A/HI/0180/2020-2021


Mr A Ponnuraj 10/23, EB Nagar, Makkinampatti 642003 2. Policy No:

Type of Policy Duration of policy/Policy period Sum Insured (SI)

500100/28/19/P1/11919556 Group Mediclaim Policy 01/11/2019-31/10/2020 INR 4,00,000

3. Name of the insured Name of the policyholder/proposer

Mr A Ponnuraj Indian Banks Association (IBA) A/c Federal Bank

4. Name of the insurer United India Insurance Company Ltd

5. Date of partial settlement of the claim 27/11/2020

6. Reason for partial settlement Settled as per guidelines of General Insurance (GI) Council for Covid 19 claims

7. Date of receipt of the Complaint 08/12/2020

8. Nature of complaint Short-settlement of the claim

9. Date of receipt of consent (Annexure VIA)

16/12/2020


11.

Amount of Monetary Loss (as per Annexure VIA)

Not furnished

12. Amount paid by the Insurer, if any INR 28,800

13. Amount of Relief sought (as per Annexure VIA)

Not furnished

14.a. Date of request for Self-contained Note (SCN)

08/12/2020

14.b. Date of receipt of SCN 16/02/2021


Rule 13(1)(b) of the Insurance Ombudsman Rules, 2017

16. Date of hearing/place By Video Conferencing (VC) on 23/02/2021


For the Complainant Mr A Ponnuraj

For the insurer Ms Srijani & Mrs Anitha Alwarswamy


19. Date of Award/Order 26/03/2021

20. Brief Facts of the Complaint:

The complainant who is covered under the respondent insurer (RI)’s Group

Mediclaim Policy issued to Federal Bank for the period from 01/11/2019 to

31/10/2020 for a SI of INR 4,00,000 was admitted to Tirupur Covid Care Center,

Tirupur on 18/10/2020 and was discharged on 24/10/2020 after undergoing

treatment for COVID 19 infection.

The reimbursement claim of INR 1,26,825 preferred by the complainant towards

the expenses incurred was settled by the RI for INR 28,800, based on the

guidelines of the GI Council.

Aggrieved by the short settlement of the claim, the complainant represented to

the RI for reconsideration of his claim for the full amount incurred, since the RI

disallowed all expenses, except the room rent. Since there is no reply from them,

he has approached this Forum for relief.

21. Insurer’s contention:

As per SCN submitted by the RI, the settlement was justified as per the GI Council

Guidelines. However, during the hearing, they agreed to settle the claim as per the

terms & conditions of the policy. Post-hearing, vide their e-mail dated 09/03/2021 they

submitted a revised working of the claim as below and confirmed that an additional

amount of INR 78, 930 is payable to the complainant.

Head of Expense

Claimed (INR)

Rejected (INR)

Allowed (INR)

Remarks

Room Rent 54,000 24,000 30,000 Allowed @ INR 5,000 per day for 6 days

Nursing 4,360 0 4,360

Consultation 15,000 0 15,000

Oxygen 6,000 0 6,000

Laboratory 2,370 0 2,370

Registration 300 0 300

Pharmacy 44,795 635 44,160 Gloves, mask – not payable

Total of Main Bill

1,26,825 24,635 1,02,190



Grand Total 1,32,365 24,635 1,07,730

Less paid already

28,800

Balance Payable

78,930


The complaint is registered under Rule13 (1) (b) of the Insurance Ombudsman Rules,

2017, which deals with “Any partial or total repudiation of claims by the life insurer,

General insurer or the health insurer”.


Complaint dated 07/12/2020 to the Insurance Ombudsman

Claim form dated 03/11/2020

Discharge Summary and bills of Tiruppur Covid Care Center

TPA’s claim settlement letter dated 27/11/2020

Complainant’s representation dated 03/12/2020 to the Insurer

RI’s response dated 12/01/2021


Self-contained Note(SCN) of the RI

RI’s e-mail dated 09/03/2021 to the Forum (revised offer of settlement)

24. Result of the hearing (Observations & Conclusion)

7. Because of the prevalent COVID 19 pandemic situation, the hearing was

conducted through VC on 23/02/2021, with the consent and participation of both

parties.

8. The Forum expresses its displeasure over the delay in submission of the SCN by

the RI.

9. The subject matter of the complaint is the RI’s partial settlement of the

complainant’s claim towards the treatment of his COVID 19 infection.

10. Though the claim was initially short settled following the guidelines of the GI

Council, during the hearing the RI agreed to settle the claim as per terms &

conditions of the policy. Accordingly, they have offered an additional amount of

INR 78,930 to the complainant, post-hearing. As per the revised working, the

deductions are an amount of INR 24,000 towards excess room rent and INR 635

towards non-medical items. The rest of the claim has been admitted. The

deductions are found to be in order and therefore, the Forum endorses the

settlement offered by the RI.

AWARD

Taking into account the facts & circumstances of the case and the documents

submitted, the respondent insurer is directed to pay the complainant an

additional amount of INR 78,930 in full and final settlement of his claim, along

with interest as defined under Rule 17 (7) of the Insurance Ombudsman

Rules, 2017.




d) According to Rule 17(6) of the Insurance Ombudsman Rules, 2017, the insurer shall comply with the

award within thirty days of the receipt of the award and intimate compliance of the same to the

Ombudsman.

e) According to Rule 17(7) of the Insurance Ombudsman Rules, 2017, the complainant shall be entitled

to such interest at a rate per annum as specified in the regulations, framed under the Insurance

Regulatory and Development Authority of India Act, 1999, from the date the claim ought to have been

settled under the regulations, till the date of payment of the amount awarded by the Ombudsman.

f) According to Rule 17(8) of the Insurance Ombudsman Rules, 2017, the award of the Insurance

Ombudsman shall be binding on the insurers.

Dated at Chennai on this 26th day of March 2021


INSURANCE OMBUDSMAN


PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF TAMIL NADU & PUDUCHERRY (UNDER RULE NO: 16/17 OF THE INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN – Shri M Vasantha Krishna CASE OF Mr M Baskaran Vs United India Insurance Company Limited

COMPLAINT REF: NO: CHN-H-051-2021-0410 Award No: IO/CHN/A/HI/0184/2020-2021


Mr M Baskaran, Plot 244, Eleventh Street, Phase I, Porur Garden, Chennai – 600 095.

2. Policy No. Type of Policy Duration of Policy/Policy Period Sum Insured (SI)

5001002819P112203988 Tailormade Group Mediclaim Policy (Retirees) (without Domiciliary Treatment cover) 01.11.2019 to 31.10.2020 INR 4 lakhs; Top-Up - INR 5 lakhs

3. Name of the Insured Name of the Policyholder/Proposer

Mrs B Lakshmi Indian Bank’s Association (IBA) A/c Indian Bank A/c Mr M Baskaran

4. Name of the Insurer United India Insurance Company Limited

5. Date of repudiation of the claims Not furnished

6. Reason for repudiation The treatment is not a listed day-care procedure and could have been managed on an out-patient (OPD) basis


8. Nature of Complaint Repudiation of the claim

9. Date of receipt of Consent (Annexure VI A)

25.01.2021


11. Amount paid by the Insurer, if any NIL

12. Amount of Monetary Loss (as per Annexure VI A)

INR 3,10,464

13. Amount of Relief sought (as per Annexure VI A)

INR 3,10,464

14. a. Date of request for Self-contained Note (SCN)

15.12.2020

14. b. Date of receipt of SCN 09.03.2021

15. Complaint registered under Rule No. 13(1) (b) of the Insurance Ombudsman Rules, 2017

16. Date of Hearing/Place By Video Conferencing (VC) on 09.03.2021


c) For the Complainant Mr M Bhaskaran

d) For the Insurer Ms Srijani




The complainant and his spouse are covered under the Group Health Insurance Policy

issued by the respondent insurer (RI) for a floating Sum Insured (SI) of INR 4 lakhs. The

policy is issued to cover the retirees of Indian Bank and their family members under an

arrangement made by the Indian Banks Association (IBA). They are also covered for a

top-up SI of INR 5 lakhs.

The complainant’s wife Mrs B Lakshmi is suffering from Breast Cancer and was

operated on at Sri Ramachandra Medical Centre (SRMC), Chennai on 28.06.2019. She

had undergone a left modified radical mastectomy and the biopsy report revealed that

she is in Stage IIIC and HER2 Positive. Her condition warranted additional therapies as

per internationally accepted norms and accordingly, the following treatment schedule

was planned:

1. Adjuvant Chemotherapy 8 cycles + Antiherto therapy 4 cycles (day-care –

inpatient)

2. Radiation therapy (Daycare – inpatient)

3. Targeted Therapy (Antiherto Injection Transtuzumab – day-care – inpatient) 18

cycles (initial 4 cycles along with chemotherapy and remaining 14 cycles – once

every 3 weeks on a standalone basis)

Dr M Manickavasagam, the treating doctor, has issued a certificate dated 18.03.2020

confirming the above line of treatment which is the universal standard of care.

The claims relating to the administration of Injection Trastuzumab alongside

chemotherapy were settled by the RI but where the injection was given on a standalone

basis, the claims were repudiated.

The complainant represented to the Grievance Department of the RI on 13.09.2020 to

reconsider their decision and he received a response through an SMS on 09.11.2020

that “As per the policy terms and conditions the current procedure is not listed under

Daycare as per condition of the policy and therefore this was recommended to IC for

rejection confirmation. Moreover, it can be managed on OPD basis. The claim has been

rejected on the basis of Terms and Conditions of the policy. Hence the deductions are

justifiably made”.

Dissatisfied with the reply, he has approached the Forum for relief.

21. (a) Complainant’s Submission:

The complainant submits that initially the claims were settled regularly but later

on, the claims for targeted therapy were rejected on the ground that the same

can be managed on OPD basis.

The injection should be administered intravenous (IV) as a day-care procedure

under strict medical supervision, which cannot be managed in OPD. The

treating doctor has also issued a certificate dated 20.11.2020 wherein, inter alia,

he has clarified that Trastuzumab is a universally accepted treatment for Breast

Cancer with Her2 positive. The injection can’t be given on OPD basis as it is an

intravenous administration and is to be monitored by medical oncologists.

The complainant has cited Clauses 2.9 and 2.10 of the policy wherein the

norms of Daycare treatment/Centre have been elaborated and has contended

that the treatment his wife underwent satisfies the norms thereof.

The treatment given is a medically necessary treatment as defined in clause

2.29 as also confirmed by the treating doctor’s certificate.

Each therapy costs more than INR 70,000 and as a senior citizen, he is finding

it difficult to afford it on a regular basis.

He has, therefore, requested the Forum to direct the insurer to settle all his

pending claims for the injection of Transtuzumab.

21. (b) Insurer’s Submission:

The RI submitted their SCN dated 04.01.2021 in which they have made the following

averments.

They have issued a Group Mediclaim Policy to the retirees of Indian Bank

(without domiciliary treatment coverage) for the period 01.11.2019 to 31.10.2020

and Policy No. is 5001002819P112203988.

The complainant and his spouse Mrs B Lakshmi are included by the Bank in the

list of insured persons. Mrs Lakshmi has been treated for Carcinoma - left breast

in SRMC, Chennai.

She was admitted to the hospital on 24.04.2020, 27.07.2020, 21.08.2020 and

14.09.2020 and was administered Injection Trastuzumab and was discharged on

the same day as the admission.

The Injection administered is a monoclonal antibody and is not a main

chemotherapy drug. The patient was admitted for no other complaints or

treatment other than the injection, which is not payable as per policy terms and

conditions. The treatment is also not covered under the daycare list of the policy.

Based on the above the claims were repudiated as per clause 3.3 of the policy

terms and conditions.


The complaint is registered under Rule No. 13(1) (b) of the Insurance Ombudsman

Rules, 2017, which concerns “Any partial or total repudiation of claims by the Life

Insurer, General Insurer or the Health Insurer”.


Complaint dated 06.12.2020 to the Insurance Ombudsman

Complainant’s representation dated 13.09.2020 to the RI

Response dated 09.11.2020 to the Complainant’s representation


Self-contained Note (SCN) of the RI dated 04.01.2021

Copy of Policy with terms and conditions

Certificates of Dr M Manickavasagam, (the treating doctor) dated 18.03.2020 and

20.11.2020


Because of the prevalent COVID 19 pandemic situation, the hearing was

conducted by VC on 09.03.2021, with the consent and participation of the

parties. Mr M Baskaran, the complainant and Ms Srijani, representative of the RI

attended the hearing.

There is a delay of more than two months in the submission of the SCN by the

RI. This Forum records its displeasure over the same.

There is also considerable delay on the part of the RI in responding to the

complainant’s representation which is in breach of the guidelines issued by the

Insurance Regulatory & Development Authority of India (IRDAI) for customer

grievance redressal. The RI should streamline its grievance redressal procedures

and avoid such delays in future.

During the hearing, the complainant reiterated the arguments made in his written

submissions and pleaded for settlement of the rejected claims.

On the other hand, the RI’s representative emphasised the fact that the treatment

undergone is not a listed daycare procedure. The injection administered is only a

monoclonal antibody and not the main chemotherapy drug. The same is not

covered as per the terms and conditions of the policy. She pointed out that the

cost of injection, when given along with chemotherapy, was reimbursed since the

latter is a listed daycare procedure. It was only the cost of standalone injections

which was rejected, for the reasons explained.

After taking into account the contentions of both sides and examining the

relevant documents and the terms & conditions of the policy, the Forum

concludes as below.

o The procedure undergone is not an OPD procedure as contended by the

RI, but a daycare procedure, although not specifically listed as a covered

daycare procedure in the policy.

o The procedure for administering the injection is very similar to that of

parenteral chemotherapy, which is a covered (listed) daycare procedure.

o The list of daycare procedures given under clause 3.3 of the Policy is

qualified with the words such as, which suggests that the list is illustrative

and not exhaustive and procedures similar to those listed therein can be

considered as covered daycare procedures. In view of what is stated

under (b) above, it is concluded that Transtuzumab injection is also a

covered daycare procedure.

o IRDAI too has directed insurers to recognise immunotherapy (monoclonal

antibody as an injection) as a covered daycare procedure, while

standardising the exclusions under health insurance policies, vide its

guidelines IRDAI/HLT/REG/CIR/177/09/2019 dated 27/09/2019. No doubt,

the directions given by the Regulator are mandatory only under policies

issued on or after 01.10.2020. But they do strengthen the argument that

immunotherapy is on par with parenteral chemotherapy, as concluded

under (c) above.

Therefore, the repudiation of the subject claims is set aside.

AWARD

Taking into account the facts & circumstances of the case and the submissions

made by the parties, the Forum hereby directs the respondent insurer to settle

the claims of the complainant for the standalone immunotherapy treatment of his

wife subject to the terms and conditions of the Policy, along with interest as

provided under Rule 17(7) of the Insurance Ombudsman Rules, 2017.




d) According to Rule 17(6) of the Insurance Ombudsman Rules, 2017, the

insurer shall comply with the award within thirty days of the receipt of the

award and intimate compliance of the same to the Ombudsman.

e) According to Rule 17(7) of the Insurance Ombudsman Rules, 2017, the

complainant shall be entitled to such interest at a rate per annum as

specified in the regulations, framed under the Insurance Regulatory and

Development Authority of India Act, 1999, from the date the claim ought to

have been settled under the regulations, till the date of payment of the

amount awarded by the Ombudsman.

f) According to Rule 17(8) of the Insurance Ombudsman Rules, 2017, the

award of the Insurance Ombudsman shall be binding on the insurers.



INSURANCE OMBUDSMAN


PROCEEDINGS OF THE INSURANCE OMBUDSMAN, DELHI

(Under Rule 13 r/w17 of the Insurance Ombudsman Rules, 2017)

Ombudsman: Shri Sudhir Krishna

Case of Subhash Chander Saluja Vs. HDFC ERGO General Insurance Co. Ltd.

Complaint Ref. No.: DEL-H-018-2021-0297

1. Name & Address of the Complainant Shri Subhash Chander Saluja WZ G1/ 52, Opp. State Bank of India, D K Mohan Garden, Uttam Nagar, Delhi-110059.

2. Policy No.

Type of Policy

PE01964079 Group Assurance Health Plan 07.01.2020 to 06.01.2021

Policy term/policy period


Name of the policy holder

Subhash Chander Saluja Subhash Chander Saluja(Group Policy of Canara Bank)

4. Name of insurer HDFC ERGO General Insurance Co. Ltd.

5. Date of repudiation 03.10.2020

6. Reason for grievance Non-settlement of Mediclaim

7. Date of receipt of the complaint 23.02.20201

8. Nature of complaint Non-settlement of Mediclaim

9. Amount of claim Rs.115000/-

10. Date of partial settlement N.A.

11. Amount of partial settlement N.A.


13. Complaint registered under Rule No of

the Insurance Ombudsman Rules 2017

Rule 13(1)(b)- Any partial or total repudiation of claims by an Insurer

14. Date of hearing 31.03.2021

Place of hearing Online Video Conferencing via Cisco WebEx App


For the Complainant 1. Shri Subhash Chander Saluja, the Complainant 2. Shri Anurag Saluja, s/o the Complainant

For the Insurer Shri Vivek Yadav, Senior Manager (Legal)

16. Date of Award/Order Award under Rule 17/ 31.03.2021

17. Brief Facts of the Case: Shri Subhash Chander Saluja (hereinafter referred to as the

Complainant) has filed this complaint against the decision of the HDFC ERGO General

Insurance Co. Ltd. (formerly, HDFC ERGO Health Insurance Ltd.) (hereinafter referred to as the

Insurers) allegingwrong rejection of Mediclaim and cancellation of the policy.

18. Cause of Complaint:

a) Complainant's Argument:The Complainant had purchased the subject policy from Canara Bank on

07.01.2020. After one month, he had a CVA stroke, which was treated, in Govt. hospital from 07.02.2020

to 12.02.2020 free of cost. On 21st September, 2020 he fell down in bathroom and was admitted in Goal

Hospitalfrom 21.09.2020 to 25.09.2020 and was diagnosed with fracture of neck of femur. He submitted

all the papers to the Insurance Company, but his claim was rejected on the grounds of non-disclosure of

prior history of head/brain surgery, diabetes, CVA stroke etc. whereas head surgery has been done after

taking the policy and diabetes was already declared at the time of taking policy. He represented his case

to Insurance Company but the Insurance Company has not settled his claim.

Case of Subhash Chander Saluja Vs. HDFC ERGO Health Insurance Ltd.


b) Insurer's Argument: The Insurance Company, vide Self Contained Note dated 30.03.2021, have

stated that on the basis of information/declaration, policy issued to the Complainant was duly

received by him. A cashless request was received from Goyal Hospital on 21.09.2020 for

Complainant for the ailment “Displaced apophyseal fracture for left femur, initial encounter for

closed fracture”. A query letter was sent for the providing the discharge summary of CVA.

Hospital submitted various certificates and past Discharge Summary as well. The patient was

admitted in RML Hospital from 07.02.2020 to 12.02.2020 and again on 03.03.2020 to 07.03.2020.

The case was sent for investigation,which reveled that patient has earlier taken treatment on

February 2018 in Janakpuri Super Speciality Hospital where it was clearly mentioned that patient

was a known case of Subdural Hygroma and has also underwent surgery of the same. The patient

was diagnosed with Ischemic Lacunar Demyelination on 27.02.2018 and was known case of

Diabetes since 2 years. It was noted from the documents that patient had a history of multiple

repeated falls. In view of the past Discharge Summary and the past treatments, the cashless as well

as the reimbursement claim was denied.

19. Reason for registration of Complaint:Non settlement of Mediclaim.

20. The following documents were placed for perusal.

a) Copy of policy.

b) Copy of GRO Letter, discharges summaries, bill, claim form, rejection letters.

c) SCN of the Insurers along with enclosures.

21. Result of hearing with the parties (Observations and Conclusion):

Case called. Parties are present and recall their arguments as noted in Para 18 above.

The claim in this complaint pertains to hospitalization of the Complainant from 21.09.2020 to 25.09.2020

for the treatment of neck fracture. The Insurers had denied the request for pre-authorisation citing the

possibility of the pre-existing disease (PED) of CVA. Subsequently, the Complainant submitted

reimbursement claim for this treatment, which the Insurers declined on 21.10.2020, and also issued

notice for termination of the policy, on the ground of non-disclosure of past history of surgery for

subdural hygroma and brain bleeding prior to 2019, that is, prior to the policy inception, citing Clause No.

7 of the Policy.

For subdural hygroma, the Insurers had relied on (a) the OPD Paper of Janakpuri Super Speciality Hospital

dated 16.02.2018, which had noted that the Complainant was k/c/o subdural hygroma and had

undergone surgery at RML Hospital and (b) the OPD Paper of Deen Dayal Upadhyay Hospital dated

29.11.2019, which had noted that the Complainant had a “h/o fall last night, bleeding from head (neuro

ref. done)”.

The Complainant has submitted an undated certificate from the Goyal Hospital,which states that the

Complainant was admitted there from 7/2/2020 to 12/2/2020 and Burr hole surgery was done during this

period and there was no history of admission prior to this surgery/admission.

The Insurers state that they do not wish to pursue the past history of diabetes of the Complainant.

Case of Subhash Chander Saluja Vs. HDFC ERGO Health Insurance Ltd.


Upon examination of the arguments and the evidence submitted by the parties, I conclude that the

certificate from the Goyal Hospital mentioned just above cannot over-rule the past medical history noted

in the OPD papers of the Janakpuri Super Speciality Hospital and the Deen Dayal Upadhyay Hospital,

mentioned before the preceding paragraph. These OPD papers had specifically noted the medical history

of the Complainant relating to subdural hygroma and bleeding from head and the Complainant had not

disclosed these facts in the policy proposal form. Therefore, the Insurers were justified in repudiating the

claim and cancelling the policy vide Clause No. 7 of the Policy terms & conditions. Pursuantly, the

complaint shall deserve rejection.

Award

The complaint is rejected.

(Sudhir Krishna) Insurance Ombudsman, Delhi

March 31, 2021


(Under Rule 13 r/w 17 of the Insurance Ombudsman Rules, 2017)


Case of Poonam Pahwa versus The Universal Sompo GeneralInsurance Company Ltd.

Complaint Ref. No.: DEL-G-052-2021-0102

1. Name & Address of the Complainant Smt. Poonam Pahwa 36, New Market, Timarpur, Delhi-110054

2. Policy No.

Type of Policy

Policy term/policy period

3333/59269494/00/000 Group Personal Accident Policy 01.01.2019 to 31.12.2019


Name of the policy holder

Satish Kumar Bhargava Karnataka Bank Ltd.

4. Name of insurer The Universal Sompo General Insurance Company Ltd.

5. Date of repudiation 17.08.2019

6. Reason for grievance Non-settlement PA death claim


8. Nature of complaint Non-settlement of PA death claim

9. Amount of claim Rs.10 lakh

10. Date of partial settlement N.A

11. Amount of partial settlement N.A

12. Amount of relief sought Rs.10 lakh

13. Complaint registered under Rule No.of

the Insurance Ombudsman Rules 2017

Rule 13(1)(b)- Any Partial or total repudiation of claims by an Insurer

14. Date of hearing 26.03.2021

Place of hearing Online Video Conferencing via Cisco WebEx App


For the Complainant 1. Smt. Poonam Pahwa, the Complainant 2. Shri Suraj Pahwa, H/o the Complainant

For the Insurer 1. Dr. Ahmad Ali, Asst. General Manager (Health Claims) 2. Smt. Anita Raghuvanshi, Sr, Executive (Legal)

16. Date of Award/Order Award under Rule 17/ 26.03.2021

19. Brief Facts of the Case: Smt. Poonam Pahwa (hereinafter referred to as the Complainant) has

filed this complaint against the decision of The Universal Sompo General Insurance Company

Ltd. (hereinafter referred to as the Insurers or the Respondent Insurance Company) allegingnon-

settlement of PA death claimon her father under a Group Personal Accident Policy through the

Karnataka Bank Ltd. (the subject policy).


a) Complainant's Argument:The Complainant’sfather Late Shri Satish Kumar Bhargava was covered under

the subject policy for sum insured of Rs.10 lakh. Hehad an accidental fall at home on 11.04.2019 while

going to the bathroom and underwent treatment at EHCC hospital. He passed away on 13.04.2019 due

to traumatic large subdural Hematoma followed by coning. She submitted all the papers to the

Insurance Company but they rejected her claim on the ground that it was a natural death whereas it

was accidental death. She approached the Grievance Cell of the Insurance Company but her claim has

not been settled.

b) Insurer's Argument: The Insurers, vide Self Contained Note dated 18.03.2021, have stated that the

Complainant had intimated the claim for compensation on the death of her father Shri Satish

Case of Poonam Pahwa versus The Universal Sompo General Insurance Company Ltd.

Complaint Ref. No.: DEL-G-052-2021-0102

Kumar Bhargava, who fell while going to the bathroom on 11.04.2019. On scrutiny of the

documents, it was revealed that the deceased was having chronic liver disease, chronic kidney

disease, and chronic artery disease and admitted with c/o sudden fall while going to bathroom

on 11.04.2019. On 13.04.2019 patient went in cardiac arrest and died due to large left subdural

hematoma with coning. The Insurance Company also stated that the factor, which led to the

fall, was because of unconsciousness and not arising out of accidental fall, as per the definition

of accident under the terms & conditions of the subject Policy. Hence, the claim was rejected as

it was natural death, which was not covered under the policy.

19. Reason for registration of Complaint:Non Settlement of PA death claim.

21. The following documents were placed for perusal.

d) Copy of policy.

e) Copy of GRO Letter, proposal form, death certificate, claim form, rejection letter.

f) SCN of the Insurer along with enclosures.

22. Result of hearing with the parties (Observations and Conclusion):


The Complainant argued that her father, the deceased life assured (DLA) was not having any

chronic ailment situation when he had this fall in the house on 11.04.2019, which is supported by

the fact that he had planned a trip to Goa in May 2019.

The Insurers argued that the Doctor Admission Assessment dated 11.04.2019 (written as

11.03.2019 and both parties agree that this date was written in error and should be taken as

11.04.2019) states that the patient was brought with sudden loss of consciousness, with no

mention of fall, even though the subsequent death summary dated 13.04.2019 mentions ‘sudden

fall’. Further, the death summary also diagnosed that the DLA was having chronic liver disease,

chronic kidney disease, chronic artery disease, thrombocytopenia, besides spontaneous subdural

hematoma with coning and pyrexia.

Upon examination of the arguments and the evidence submitted by the parties, it is concluded

that the DLA had a fall on 11.04.2019, which had developed on account of his other chronic

ailments and, therefore, this fall could not be classified as ‘accident’. Pursuantly, the death claim

on his life was not admissible under the subject policy and the complaint would deserve

rejection.

Award

The complaint is rejected.


March 26, 2021 .


(Under Rule 13 r/w 16 of the Insurance Ombudsman Rules, 2017)


Case of Ramesh Kharbanda Versus The New India Assurance Company Ltd.



Shri Ramesh Kharbanda (hereinafter referred to as the Complainant) has filed this complaint against the

decision of the New India Assurance Company Ltd. (hereinafter referred to as the Insurers or the Respondent

Insurance Company) alleging inadequate settlement of mediclaim.


a) Complainant's Argument:

The Complainant was admitted to Apollo Hospital, Chennai for his Medical Treatment. During the

hospitalization period 10.10.2019 to 12.10.2019, the total expense was Rs. 108576/- but the TPA Vipul

approved cashless for Rs.59081/- only. He took up the matter with the Insurers for balance payment Rs.

49495/-, but they denied it stating that the amount Rs. 49495/- has been deducted under the Proportionate

clause as per terms and conditions of the Policy. He wrote to the GRO on 30.10.2020 but the Insurers still did

not reimburse the amount stating the same reason. He has now approached this forum for relief.

1. Name & Address of the Complainant Shri Ramesh Kharbanda IA-32B, Phase-1, Ashok Vihar, Delhi-110052


97000034190400000040 New India Flexi Floater Group Mediclaim Policy 16.08.2019 To 15.08.2020

3. Name of the insured Name of the policy holder

Ramesh Kharbanda Inthree Access services Private Limited

4. Name of the insurer The New India Assurance Company Ltd.

5. Date of repudiation N.A.

6. Reason for repudiation N.A.


8. Nature of complaint Inadequate Settlement of Mediclaim

9. Amount of claim Rs. 108576/-

10. Date of partial settlement 12.10.2019

11. Amount of partial settlement Rs. 59081/-

12. Amount of relief sought Rs. 49495/-

13. Complaint registered under Rule No. of the Insurance Ombudsman Rules, 2017

Rule 13(1)(b) – any partial or total repudiation of claims by an insurer

14. Date of hearing/place 24.03.2021, Delhi, Online, Via WebEx


For the Complainant Shri Ramesh Kharbanda, the Complainant

For the insurer 1. Smt. Meenakshi Bhaskaran, Administrative Officer, Large Corporate Business, Chennai 2. Smt. Usha Khaneja, Manager (RTI & Grievances), RO-1, Delhi

16. Complaint how disposed/ Date of Award/Order

Recommendation under Rule 16 24.03.2021

Case of Ramesh Kharbanda Versus The New India Assurance Company Ltd.


b) Insurer's Argument:

The Insurers in their SCN dated 03.03.2021 have stated that the Complainant was hospitalized in Apollo

Hospital, Chennai from 10.10.2019 to 12.10.2019 for his treatment. The Total Bill of the hospital was Rs.

108576/- and cashless was approved for Rs. 59081/- by TPA with deductions of Rs.49495/- under the

proportionate clause. The Complainant had opted for higher category Room Rent @ 10750/- per day, while

as he was entitled for Rs.6000/- per day, therefore proportionate clause was applied and excess amount was

deducted. Hence the claim was rightly paid for Rs. 59081/-, based on terms and conditions of the policy.

19. Reason for registration of Complaint: Inadequate settlement of Mediclaim.

20. The following documents were placed for perusal:

a) SCN

b) Letter to GRO

c) Discharge Summary

21. Result of hearing of the parties (Observations and Conclusion):


At this stage, the Insurers offer to make an additional payment of Rs. 30,000 in full and final settlement of

the matter, within 30 days. The Complainant accepts this offer. Thus an agreement of conciliation could be

arrived at between the Complainant and the Insurers, which I consider as fair and reasonable for both the

parties.

Award

The complaint is resolved in terms of the agreement of conciliation arrived at between the Complainant

and the Insurers. Accordingly, the Insurers shall make an additional payment of Rs. 30,000 in full and

final settlement of the matter, within 30 days.


March 24, 2021

AWARD NO.IO/KOC/A/HI/0477/2020-2021

PROCEEDINGS OF

THE INSURANCE OMBUDSMAN, KOCHI

(UNDER RULE NO. 13 1(b) READ WITH RULE 14 OF

THE INSURANCE OMBUDSMAN RULES, 2017)

Complaint No. KOC-H-044-2021-0752

PRESENT: Ms. POONAM BODRA

INSURANCE OMBUDSMAN, KOCHI.

AWARD PASSED ON 10.03.2021

1. Name and Address of the

complainant

: Mrs. Cicily George

C/o Shaji Kumar, Palathinkal House, Near

Pettah Bridge, Thripunithura-682301

2. Policy Number

: P/180000/01/2019/000869

3. Name of the Insured

: Mrs. Cicily George

4. Name of the Insurer

: STAR HEALTH AND ALLIED INS. CO. LTD.

5. Date of receipt of Complaint

: 15.01.2021

6. Nature of complaint

: Partial rejection of mediclaim

7. Amount of relief sought

: --

8. Date of hearing

: 02.03.2021

9. Parties present at the hearing

a) For the Complainant

: Mr. Shajikumar(online)

b) For the Insurer : Mr. Manu Mohan(online)

AWARD

This is a complaint filed under Rule 13 1(b) read along with Rule 14 of the Insurance Ombudsman Rules,

2017. The complaint is regarding partial rejection of mediclaim. The complainant, Mrs. Cicily George is

the policyholder.

1. Averments in the complaint are as follows:

The Complainant stated that she is a Group policy holder through St Mary’s Forane Church with Sum

Insured of Rs. 2 lakhs. She was admitted in Lissie hospital for treatment , from 23/2/2020 to 29/2/2020.

She spent Rs 1,28,214/- but her claim was settled for Rs. 16,500/- only on 12/10/2020. She requests the

Ombudsman to get her the entitled amount.

2. The Respondent Insurer entered appearance and filed a self contained note. It is submitted that 1.

The Welfare Services Ernakulam took a Group Health Insurance for the period from 01/03/2019

to 29/02/2020 in which the complainant was covered for a Sum Insured of Rs 2,00,000/-

It is submitted that the complainant, was admitted at Lisie Hospital, Ernakulam on 23/02/2020 for the

treatment of Massive Upper GI bleed with shock, Duodenal Varies with stigmata of bleed, EUS guided

coil and glue injection, Cirrhosis of liver with portal HTN and Hypertension and after treatment she was

discharged on 29/02/2020.

After the treatments were over, the complainant has submitted completed claim form, Discharge

summary, Bills of Rs. 1,28,218/- and Lab reports.

It is submitted that the following sub limit are applicable in the group policy as follows:-

It is pertinent to note that under the special condition clause of the policy the following would also apply

viz,

1 Room Rent Limits

including Boarding,

Nursing Charges etc

For Normal room rent restricted to Rs.1100/- per day

(Rs.12,500/- per Hospitalization and for ICU : Rs.1500 per

day.

Nursing Fee restricted to Rs.150/- per day .

Dr. Fee (Plus all other professional fee) restricted to

Rs.18,000/- per hospitalization.

Blood, Oxygen, Diagnosis and medicine – Rs.1500 per day

(Rs.2000/- whilst in ICU).

2 Co-pay 30% Co-Pay will be applicable for insured above 60 years

Based on the claim documents, the company had processed the claim and approved an amount

of Rs.16,500/- on 10/09/2020 and the same was credited to the proposer`s account. The details are as

follows:-

Sl.No Particulars Total claimed

amount

Deducted amount and

items

Total admissible

Amount

1 ICU RENT Rs.1950/- Rs.1950/-

3 ROOM RENT Rs.1650/- Rs.1650/-

4 NURSING CHARGE( 6 days ) Rs.4650/-

As per policy norms Nursing

Fee restricted to Rs.150/-

per day . Hence Deducted

for Rs. 3750/-

Rs.900/-

5 PROFESSIONAL Rs.2640/- Rs.2640/-

6 ANESTHESIA CHAREG Rs.2000/- Rs.2000/-

7 GASTRO PROCEDURE Rs.15500/- Rs.15,500/-

8 ENERGY & WATER Rs.1350/-

Room rent already

considered fully. So

additional energy & water

charge not payable.

Rs.1350/-

9 MONITORING Rs.900/- Rs.900/-

10 EXCESS RENT Rs.1650/-

Additional room rent not

payable : Rs.1650/-

11 ACCESSORIES COST Rs.24000/-

Details not submitted

.Hence Consumable and

non payable amount

deducted for 50% :

Rs.12,000/- Rs.12,000/-

12 ADMISSION Rs.180/-

Admission charges not

payable : Rs.180/-

13

MEDICINE Rs.6567/-

Consumable and Non

payable items not payable

Mask, Handrub, Bag, Bed

bath, syringe pump,

Glucometery strips

,biomedical waste

managment and other non

payable). Hence deducted

for Rs.3227/-

Rs.3,340/-

14 MEDICINE Rs.19810/-

As per policy norms Blood,

Oxygen, Diagnosis and

medicine – Rs.1500/- per Rs.7160/-

day for Room and Rs.2000/-

per day for ICU . Hence

deducted for Rs. 12,650/-

15 LAB CHARGE Rs.18980/-



medicine – Rs.1500/- per



deducted for Rs. 18070/-,

Cross matching & blood

group not payable; Rs.910/-

16 LAB Rs.1140/-






deducted for Rs. 1140/-

17 OXYGEN Rs.1310/-







18 XRAY Rs.260/-







19 OT CONSUMPTION Rs.20421/-






deducted for Rs. 20,421/-

20 SERVICE CHARGE Rs.120/-

Service charges not payable

: Rs.120/-

21 FILE CHARGE Rs.20/-

File charges not payable:

Rs.20/-

22 PROCEDURE Rs.1865/- Rs.1865/-

23 NURSING PROCEDURE Rs.1255/-

Injection charges , Sponge

bath and Pulse oxymeter

not payable: Rs.350/- Rs.905/-

In short, the Company has approved the claim as per the terms and conditions of the policy and hence

the complainant is not entitled to any further amount.

Hence, pray that respondent insurer may be totally exonerated from any liability under the claim.

3. I heard the Complainant and the Respondent Insurer. The Complainant submitted that she was

covered under a group policy and as against hospitalization expenditure of Rs. 1,28,214/- , claim was

settled for Rs. 16,500/- only and there was no response from the Ins. Co.to her further request . The

Respondent Insurer submitted that the claim was processed under the Group policy terms according to

which room rent, diagnostics etc are limited to specific amounts. However, on reprocessing, it was

found that a balance amount of Rs.19,067/- is payable.

4. I have heard both the sides and perused the documents and observed the Special Conditions

applicable under the Group Policy issued and gone through the claim computation. The respondent

insurer has paid Rs.16,500/- and the Balance Admissible Claim amount is Rs. 19,067/-

In the result, an award is passed, directing the Respondent Insurer to pay an amount of Rs. 19,067/- ,

within the period mentioned hereunder. No cost.

Total Bill Amount Rs. 1,28,218/-

Non Payable Amount Rs.77,408 /-

Total Admissible amount Rs.50,810/-

After apply 30 % Copayment Rs.35,567/-

Total Payable Amount Rs.35,567/-

Already paid amount Rs. 16,500/-

Balance payable Amount Rs. 19,067/-

As prescribed in Rule 17(6) of Insurance Ombudsman Rules, 2017, the Insurer shall comply with the

award within 30 days of receipt of the award and intimate compliance of the same to the Ombudsman.

Dated this the 10th day of March 2021.

Sd/-

(POONAM BODRA)

INSURANCE OMBUDSMAN


PROCEEDINGS OF









complainant

: Mr. Lawrence M C,

Holy Family House, Valia Veli P O,

Thiruvananthapuram, Pin-695021

2. Policy Number

: 120200/28/18/P114266843


: Mr. Lawrence M C


: The United India Insurance Co. Ltd.


: 18.12.2020


: Rejection of mediclaim


: --

8. Date of hearing

: 02.02.2021


c) For the Complainant

: Mr. Lawrence M C (online)

d) For the Insurer : Ms. Vinita Sangah & Dr. Ketki (online)

AWARD


2017. The complaint is regarding rejection of mediclaim. The complainant, Mr. Lawrence M C is the

policyholder.


The Complainant stated that he is a SBI Pensioner. He along with his wife were covered under SBI

Pensioners Group Mediclaim policy, Type B-Non Domicilliary bearing Policy No.1202002818P114266843

issued by respondent insurer United India Insurance Co Ltd, the TPA is MD INDIA with MD ID: MDI5-

0032030556. The complainant insured along his wife were admitted in KIMS HOSPITAL on 06/03/2019

and the hospital sent a cashless request to the TPA on 07/03/2019, which was rejected by the TPA on

20/03/2019 stating the reason of Genetic Disorders. He underwent Kidney Transplant on 08/03/2019,

the Kidney donor was his wife Mrs.Gillus and she was discharged on 11/03/2019. He was discharged on

20/03/2019. In the cashless denial letter of the TPA, it is mentioned that the policyholder may submit

the claim as reimbursement claim subject to the terms and conditions of the policy. So he submitted

the claim bills for reimbursement on 04/04/2019 and was waiting for the reply. In spite of his reminder

mails and letters to various offices of SBI, on 16/01/20 an officer at SBI CMHR had forwarded a mail

received from MD INDIA that their claims were rejected; the attached rejection letters were dated

16/04/2019 for Mrs.Gillus and 17/04/2019 for Lawrence(self), but the original bills were not returned

along with. On getting the rejection letter, he requested MD INDIA on 16/01/2020 to return his original

medical bills for applying for SBI Assistance, which is a scheme to help the retired SBI employees

suffering from Critical Illnesses, but on 11/06/2020, they gave him its scanned copies only attested by

MD INDIA doctor. The SBI Assistance rejected his application for assistance due to the following reasons

a) The application pertains to Medical Expenses incurred in FY 2018-19

b) Original Bills not submitted

Reason (a) could not be complied by him as MD INDIA did not gave originals bills in time to apply for SBI

Assistance; they gave originals on 14/12/2020, one and half years after the rejection.

Reason (b) could not be complied by his as MD INDIA did not give originals to apply for SBI Assistance,

they gave him only scanned bills attested by Doctor.

If MD INDIA returned his original claim bills immediately after rejection of claims, he could have

submitted the original in time for SBI Assistance and got eligible amount to him.

Since MD INDIA, TPA of United India Insurance Co ltd disabled him from getting the eligible amount, he

submitted an online complaint to United India Insurance co Ltd on 17/11/2020 asking them to give him

the eligible amount, but the reply was ignoring his request. After his online request to United India, the

TPA, MD INDIA returned his original bills on 14/12/2020 (after one and a half years).

2. The Respondent Insurer entered appearance and filed a self contained note. It is submitted that as

per the complaint received, the patient is retired employee of State Bank of India. He underwent Kidney

Transplant on 08/03/2019 along with the donor. On claiming for cashless access for treatment, his claim

was denied by MD India TPA stating it was Genetic Disorder. Later the complainant submitted the bills

for reimbursement which were also rejected by TPA and complainant did not get his original claim

documents back.

The documents received from MD India TPA Pvt Ltd as are follows:-

(a) Claim No.MDI 4764202, TPA had received the claim form from Mrs.Gillus for Rs.1,07,342/-.

During hospitalization, she was treated with Laparoscopic Left donor nephrectomy. It was

observed that the patient was treated for polycystic kidney disease which is a genetic disorder

and the expenses incurred towards genetic disorders are not payable. Hence the claim has been

repudiated as per policy condition no.4.16.

(b) Claim No.MDI4766701, TPA had received the claim from Mr. Lawrence MC for Rs.6,16,942/-. He

was diagnosed with Autosomal Dominant Polycystic Kidney disease. He was treated with

nephrectomy. Polycystic Kidney disease being a genetic disorder and the expenses incurred

towards genetic disorders & its complication are ot payable. Hence the claim has been

repudiated as per policy condition no.4.16.

On 10/04/2019, TPA had received claim documents of Mr.Lawrence MC. After scrutinizing the claim

documents, it is observed that the claim is not payable according to terms and conditions of the policy,

hence claim had been recommended for repudiation on 17/04/2019. As a standard operating

procedure, the claim was referred to the Broker for opinion. Thereafter it was referred to SBI CMHR for

opinion. On 16/01/2020, it has been informed by SBI CMHR to the insured that the case has been

repudiated and hence insured received claim repudiation message on the same day. On 02/06/2020,

TPA received Email from the broker asking for the case status. On the same day they had responded

with case details and claim documents. On 05/06/2020, they had received email from Broker to return

Physical claim files to the insured. Due to high peak time of the Pandemic situation, most of the

employees were working from Home. However they managed to share the scan documents, with the

insured and SBI CMHR.

They had not received any communication from insured that the bills are rejected by SBI Assistance due

to the reason non-submission of original claim documents. On lodging of grievance at UIIC portal dated

18/11/2020 for return of original claim documents to the insured, the same has been dispatched by TPA

to SBI CMHR of Trivandrum region on 07/12/2020 having POD No.R38995226/DTDC, keeping SBI CMHR

& Broker in email communication.

The company has examined all records available at the policy issuing office and has also made inquiries

with the Third Party Administrator responsible for servicing the claims arising out of the above referred

policy. It is learnt from the examination and inquires that :-

(a) The claim of MC Lawrence and Mrs.Gillus Lawrence have been rightly repudiated by the TPA as

Genetic Disorder as per policy condition No.4.16.

(b) Due to strict lockdown conditions, all working from home and with limited accessibility, it was

only possible to return the original documents to the insured on 07/12/2020.

In view of the above circumstances it is submitted that the decision taken by the company is strictly in

accordance with the terms and conditions of the policy issued.

3. I heard the Complainant and the Respondent Insurer. The Complainant submitted that he spent a

total amount of Rs.11,04,77/- out of which the IP Bill amounting to Rs.36,883/- get reimbursed. Now he

is approaching this forum for the relief sought for an amount of Rs.10,67,894/-. He submitted a Circular

No.CDO/P&HRD-IR/85/2012-13 dated 11/03/2013 regarding the Assistance to Retired Employees in

case of Critical Illness. The coverage under the scheme is – All employees of State Bank of India on

superannuation from the Bank of those who have taken VRS after attaining 58 years of age, their

spouses and disabled children, if any, shall be covered under the scheme. The scheme will cover

medical expenses incurred by the retired employees/family pensioners on or after 1st April of the

financial year for critical diseases.

Diseases Covered:- Medical expenses incurred on critical illness in respect of specified diseases as

mentioned below shall be covered.

Sl.No. Name of Disease

1 Cancer

2 Cardiac Surgery/Serious Heart Ailments

3 Kidney/Liver Transplant

4 Dialysis

5 Illness/Accidents of serious nature involving major

surgeries/life support system

The Bank shall provide assistance to the extent of 50% of the medical expenses incurred above the

amount payable under the medical scheme/insurance policy. The maximum amount of assistance shall

be restricted to Rs.5 lacs. The Respondent Insurer submitted that the relevant policy bearing

no.1202002818P114266843 has been confirmed to have been issued by Divisional Office-8, Mumbai of

the company for the period 16/01/2019 to 15/01/2020. It is submitted that two claims on claiming

cashless treatment were denied by the MD India TPA stating it was Genetic Disorder, later the

complainant submitted the bills for reimbursement which were also rejected by the TPA and

complainant did not get his original claim documents back. The details of the two claims are as detailed

(a) Claim No.MDI4764202 pertains to Mrs,Gillus(donor) for Rs.1,07,342/-. During hospitalization

she was treated with Laparoscopic Left donor nephrectomy.

(b) Claim No.MDI4766701 pertains to Mr.Lawrence MC for Rs.6,16,942/-. He was diagnosed with

Autosomal Dominant Polycystic Kidney Disease. He was treated with nephrectomy.

Both the claims were repudiated for the reason that Polycystic Kidney Disease being a genetic disorder

are not payable as per policy conditions.

4. After hearing the complainant and the respondent insurer and perusing the exhibits produced, I find it

appropriate in the interest of justice to direct the insurer to pay Rs.5,00,000/- which is the maximum

amount of assistance offered by the SBI Assistance to their retired staff in case of critical illness. The

total of both the claims comes to Rs.7,24,284/-, for hospitalization expenses incurred for him along with

his wife. This forum not considered the other bills and claims raised by the claimant during the hearing

as these are either pre and post hospitalization or not connected to this hospitalization.

In the result, an award is passed, directing the Respondent Insurer to pay an amount of Rs.5,00,000/-,





Sd/-

(POONAM BODRA)

INSURANCE OMBUDSMAN


PROCEEDINGS OF









complainant

: Mr. Harikrishnan K N

Panchajanyam, Kalarikkal Gardens, Eroor West

P.O, Tripunithura

2. Policy Number

: P/141129/01/2021/000129


: Mr. Harikrishnan K N


: STAR HEALTH AND ALLIED INS. CO. LTD.


: 11.12.2020




: --

8. Date of hearing

: 28.01.2021


e) For the Complainant

: Mr. Harikrishnan (online)

f) For the Insurer : Mr. Manu Mohan(online)

AWARD


2017. The complaint is regarding rejection of mediclaim. The complainant, Mr. Harikrishnan K N is the

policyholder.


The Complainant stated that he was hospitalized at the Lakeshore Hospital, Ernakulam from 26.9.20 to

5.10.20, with covid-19. The claim expenses of Rs.1,27,374/-, was rejected by the respondent insurer

stating that as per the respondent insurer`s mediclaim team, the patient`s general condition and vitals

were stable throughout the admission. The quantum of relief sought is Rs.1,26,874/-.

2. The Respondent Insurer entered appearance and filed a self contained note. It is submitted that Six

Dee Telcom Solutions Pvt. Ltd., Banglore, took a Group Health Insurance for the period 3.7.20 to 2.7.21,

for a sum insured of Rs.2lacs.The complainant was admitted at the Lakeshore Hospital, Ernakulam, for

the period 26.9.20 to 5.10.20 with Covid-19 Category A, Asymptomatic. Standard Q Covid 19 Antigen

test/RT – PCR Positive, on 26.9.20. The claim form, bills for Rs.1,30,977/-, discharge summary & lab

reports were submitted. On scrutiny of the records, it was found that the patient was diagnosed as

Covid 19 Category A-Asymptomatic and no active line of treatment was given but only vitamins, tablets

prescribed. Here the patient was asymptomatic and hospitalization was not warranted and hence he

was isolated and monitored for 10days. There were no symptoms requiring inpatient care/admission in

the hospital. As per the records it was clear that the patient was asymptomatic and his vitals were stable

and stayed in the hospital only for observation/monitoring i.e. institutional quarantine. Hence the claim

was repudiated.

3. I heard the Complainant and the Respondent Insurer. The Complainant submitted that on testing

Covid positive – Category A, was admitted in the Lakeshore Hospital, Ernakulam, for the period 26.9.20

to 5.10.20. The claim when lodged was denied stating that throughout the admission, his vitals were

normal. The Respondent Insurer submitted that the patient was diagnosed with Covid 19 , Category A -

Asymptomatic and no active line of treatment was given but only vitamins & tablets were prescribed.

The complainant was asymptomatic and hospitalization was not warranted and hence he was isolated

and monitored for 10days.

4. I heard the complainant and the respondent insurer and had gone through the records. In this case

the complainant was tested Covid Positive – Category A and was admitted in the hospital for the period

26.9.20 to 5.10.20. The arguments put forth by the respondent insurer that the hospitalization claim

when lodged was denied stating that:- no active line of treatment was given but only vitamins & tablets

were prescribed and hospitalization was not warranted and hence he was isolated and monitored for

10days, was not convincing. The respondent insurer was therefore directed to submit the admissible

amount. The admissible amount submitted is as follows :-

PARTICULARS

CLAIM

AMOUN

T

DEDUCTE

D

AMOUNT

PAYABL

E

AMOUN

T DEDUCTION REASON

ADMISSION 330 330 0 ADMISSION

LAB 3970 3970

ECG 330 330

NUTRITIONAL 230

230 NUTRITIONAL -PAYABLE

LAB 210 210

LAB 360 360

consul 8400 8400

FOOD 450 450 0 FOOD CHARGE

ISOLATION 12150 4150 8000

PP KIT RS 2000/-PER DAY

MAXIMUM PAYABLE

ISOLATION (4 days )

LAB 760 760

MISCELLANEOUS 500 500 0 MISCELLANEOUS

LAB 850 850

NURSING 32400 32400

ROOM 31500 27900 3600

ROOM + NURSING (2% OF SI

MAXIMUM PAYABLE )

DIET 3520 3520 0 DIET

X RAY 610 610 0 X RAY FILM NOT ENCLOSED

CONSUMBALE 975 975 0 ID TAG ,HAND WASH , PAPPER

CONSUMABLE 26029 20029 6000

MASk, FACE SHEILD ,CAP

,GLOVES ,GOWN ,PP KIT RS

1200/- PER DAY MAIMUM

PAYABLE (5 day )

MEDICINE 2301 2301

MEDICINE 375 375 0 HAND RUB

PRE LAB 625 625 0 LAB REPORT NOT ENCLOSED

CONSU 500 200 300 REGISTARTION

MEDICINE 3517 3517 0

CREDIT BILL NO CASH PAID

CONFIRMATION SEAL

MEDICINE 85 85 0

CREDIT BILL NO CASH PAID

CONFIRMATION SEAL

130977 67711

TOTLA BILL AMOUNT =

RS 130977/-

TOTAL PAYABLE

AMOUNT = RS 67711 /-

The respondent insurer has to pay the admissible amount of Rs.67,711/-, subject to submission of

bills/records.

In the result, an award is passed, directing the Respondent Insurer to pay an amount of Rs.67,711/-,

subject to submission of bills/records, within the period mentioned hereunder. No cost.




Sd/-

(POONAM BODRA)

INSURANCE OMBUDSMAN

.

AWARD NO. IO/KOC/A/HI/0488/2020-2021

PROCEEDINGS OF








1. Name and Address of the complainant

: Mr. K G Panicker

Upasana, Kurichimuttom, Edayaranmula

P.O, Kozencherry Pin-689532

2. Policy Number

: 310300/34/19/04/0000001


: Mrs. Jagadha


: The New India Assurance Co. Ltd.


: 11.01.2021


: Non payment of mediclaim


: --

8. Date of hearing

: 23.02.2021



: Consent Given

b) For the Insurer : Ms. Hyma Soman

AWARD


2017. The complaint is regarding non payment of mediclaim. The complainant, Mr. K G Panicker is the

policyholder.


The Complainant a SAIL retiree aged 78 years and his spouse are the beneficiaries of the SAIL mediclaim

with the respondent insurer. His spouse was hospitalized on an emergency basis at the Century Hospital,

Mulakkuzha, Chenganur for the period 18.7.19 to 23.7.19. All documents including additional

documents requested were submitted. The claim is pending settlement.

2. The Respondent Insurer entered appearance and filed a self contained note. It is submitted that the

complainant`s spouse, 70 years was admitted at the Century Hospital, Chenganur with Acute Infective

Exacerbation of Bronchial Asthma & HTN, from 18.7.19 to 23.7.19. She was treated with

bronchodialaters, antibiotics, antihistamines with supportive management.The claim amount is

Rs.18,597/-. The following additional mandatory documents 1. X-ray report 2.CI delay compliance ,

which were requested were not received till date . Hence the claim was closed on grounds of Non

Compliance of required documents. The SI is Rs.4lacs. and the policy period is from 11.7.19 to 10.7.20 .

The policy no. is 310300/34/19/04/0000000/1.

3. I heard the Respondent Insurer as the complainant requested to consider the claim on its merits. The

Respondent Insurer submitted that the following additional mandatory documents 1. X-ray report 2.CI

delay compliance , of the complainant`s spouse, 70 years, who was admitted from 18.7.19 to 23.7.19, at

the Century Hospital, Chenganur , with Acute Infective Exacerbation of Bronchial Asthma & HTN, which

were requested, were not received till date . The claim was closed on grounds of Non Compliance of

required documents.

4. I heard the respondent insurer and had gone through the records submitted by the complainant and

then respondent insurer. In this case, the argument put forth by the respondent insurer was that the

hospitalization claim of Rs.18,597/-, of the complainant`s spouse aged 70 years, admitted for the

treatment of Acute Infective Exacerbation of Bronchial Asthma & Hypertension from 18.7.19 to 23.7.19,

was denied for non submission of required documents. It is noted that the complainant had kept postal

records (speed post counter foil) along with complaint letter stating that all necessary documents were

dispatched to the respondent insurer/TPA. On analyzing the situation and facts, the respondent insurer

is directed to pay the admissible claim amount of Rs.18,597/- subject to submission of

duplicate/Photostat copies of bills/records, attested by an Insurance Co. Officer/ Gazette Officer.

In the result, an award is passed, directing the Respondent Insurer to pay the admissible claim amount

of Rs.18,597/- subject to submission of duplicate/Photostat copies of bills/records, attested by an

Insurance Co. Officer/ Gazette Officer, within the period mentioned hereunder. No cost.




Sd/-

(POONAM BODRA)

INSURANCE OMBUDSMAN


PROCEEDINGS OF









: Mr. Vijayan Pillai K K,

Kandananikkal House, Sankarappilly, Muttom P

O, Idukki DistriPin-685587

2. Policy Number

: 2817/51173962/08/000


: Mr. Vijayan Pillai K K


: Universal Sompo Gen. Insu. Co. Ltd.


: 21.12.2020




: --

8. Date of hearing

: 23.02.2021



: Mr. Vijayan Pillai (online)

b) For the Insurer : Dr. Ahmed(online)

AWARD


2017. The complaint is regarding rejection of mediclaim. The complainant, Mr. Vijayan Pillai K K is the

policyholder.


he Complainant stated that his spouse was admitted at the Chazikath Hospital, Thodupuzha with

Dengue Fever from 21.3.19 to 27.3.19. The original claim bill/s for Rs.21,413/-, discharge summary,

ultrasonography- abdomen & pelvis, CT-whole abdomen(plain) were send to the respondent

insurer.However on 25.2.20. Rs.8,966/- only was credited in his IOB, Thodupuzha. He had taken up with

the grievance cell of the respondent insurer for the balance claim amount settlement , but yielded no

result. Prayed for the settlement of the balance claim amount of Rs.12,447/-.


insured was covered under the IOB Care Plus Insurance which covers the period 28.1.20 to 27.1.20. The

complainant`s spouse was admitted at the Chazikattu Hospitals Pvt. Ltd., Thodupuzha for the period

21.3.19 to 27.3.19. On verification of the claim documents received, claim amount of Rs.8,966/- was

paid as per the terms & conditions of the policy . Amount not paid is shown below:-

Expns. Head Amt.Rs. Reason for deduction

Profsnl. Crgs 350 Procedure crgs, part of nursing crgs

Misc. Crgs 8361 Photocopy bill attached

Room & Nursing 130 Consultation paper not attached

Invstg. Crgs 810 Consultation paper not attached

Misc. Crgs 120 Non payable

Room & Nursing 120 Consultation paper not attached

Profsnl. Crgs 120 Consultation paper not attached

Invstg. Crgs 195 Consultation paper not attached

3. I heard the Respondent Insurer as the complainant requested to consider the claim on its merits. The

Respondent Insurer submitted that the complainant`s spouse was admitted with Dengue fever at the

Chazikattu Hospitals Pvt. Ltd., Thodupuzha for the period 21.3.19 to 27.3.19. On verification of the claim

documents received, claim amount of Rs.8,966/-, was settled as per the terms & conditions of the policy

on 26.2.20. Some of the original bills were not submitted by the complainant.

4. I heard the Respondent Insurer and had bone through the records submitted by them. In this case

the complainant`s spouse, 59 years old female was admitted at the hospital from 21.3.19 to 27.3.19,

with Dengue Fever. The original claim bill for Rs.21,413/-, discharge summary, ultrasonography-

abdomen & pelvis, CT-whole abdomen(plain) were send to the respondent insurer but the claim was

settled only for Rs.8,966/-. The complainant had kept records of his postal dispatch of documents along

with the complaint letter stating that he had dispatched necessary documents. On analyzing the

situation and facts, the respondent insurer is directed to pay the balance admissible amount to the

complainant subject to receipt of the photocopies of shortfall bills/records, attested by a Gazette

Officer/Insurance co. Officer.

In the result, an award is passed, directing the Respondent Insurer is directed to pay the balance

admissible amount to the complainant subject to receipt of the photocopies of shortfall bills/records,

attested by a Gazette Officer/Insurance co. Officer, within the period mentioned hereunder. No cost.




Sd/-

(POONAM BODRA)

INSURANCE OMBUDSMAN


PROCEEDINGS OF









: Mrs. Manju N,

Illath House, Alium kadav, P O, Karunagappally,

Kollam-690573

2. Policy Number

: 2850/61675367/00/000


: Mrs. Manju N




: 11.01.2021




: --

8. Date of hearing

: 23.02.2021



: Ms. Manju N (online)

b) For the Insurer : Dr. Ahmed(online)

AWARD


2017. The complaint is regarding rejection of mediclaim. The complainant, Mrs. Manju N is the

policyholder.


The Complainant stated she is holding the health policy of the respondent insurer for more than 6years.

On 14.8.20, she underwent surgery for Cyst in the Uterus, at the Travancore Medicity Hospital, Kollam.

All those documents requested on various occasions were given. The claim was rejected without giving

reasons. The complainant prayed for the settlement of the claim. Policy number is

2850/61675367/00/000.


complainant covered under the IOB Health Care Insurance for the period 7.8.2 to 6.8.21.The policy

number is 2850/61675367/00/000. The complainant was hospitalized for the period 12.8.20 to 19.8.20

at Travancore Medical College Hospital. Time and again several letters were issued to the complainant

for submission of necessary documents for the assessment of the claim and lastly the claim was closed.

The documents/clarifications needed were: 1. Treatment record related to TAH. 2. All original payments

related to abdominal mass. Deficiency letters send were dated 28.11.20, 29.11.20 and claim repudiation

letter was send on 21.12.20.

3. I heard the Complainant and the Respondent Insurer. The Complainant submitted that the claim

expense for surgery for removing Cyst in the Uterus was rejected without giving reasons. All those

documents requested by the respondent insurer were also submitted. The complainant prayed for the

settlement of the claim. The Respondent Insurer submitted that the complainant is covered under the

IOB Health Care Insurance for the period 7.8.20 to 6.8.21, for a sum insured of Rs. 2lacs for

Hospitalisation – Floater sum insured & Rs.2lacs for Personal Accident. The complainant was

hospitalized for the period 12.8.20 to 19.8.20 at Travancore Medical College Hospital, diagnosed with

Right Sided Mucinous Cystadenoma Ovary and Laparotomy with Right Oophorectomy done on 13.8.20.

As per the discharge summary the Complainant aged 44 years old P2L2 presented with Mass Per

Abdomen and Recurrent UTI for 7-8 months. She had history of heavy menstrual bleeding and a history

of Anemia corrected with 2 PINT PRBC from 28years of age and total Abdominal Hysterectomy and Left

Salpingo Oophorectomy was done at 35years of age for Abnormal Uterine Bleeding. The

documents/clarifications required were unanswered by the complainant: 1. Treatment record related to

TAH. 2. All original payments related to abdominal mass. Several letters sent to the complainant were

unanswered and finally the claim repudiation letter was sent on 21.12.20.

4. I heard the Complainant and the respondent insurer and had gone through the records submitted. In

this complaint the complainant`s hospitalization claim for surgery of Cyst in the Uterus was denied by

the Respondent insurer without assigning any reasons. The counter arguments put forth by the

respondent insurer were :1. The complainant was hospitalized upon diagnosing with Right Sided

Mucinous Cystadenoma Ovary and Laparotomy with Right Oophorectomy. 2. The discharge summary

indicated that the Complainant aged 44 years had history of heavy menstrual bleeding and h/o Anemia

corrected with 2 PINT PRBC from 28years of age and total Abdominal Hysterectomy and Left Salpingo

Oophorectomy was done at the age of 35years for Abnormal Uterine Bleeding.

3. The complainant`s treatment records related to TAH and all original payments related to the

abdominal mass still remains unclarified and hence the claim was denied; are all tenable. I therefore do

not want to interfere in the decision of the respondent insurer in denying the claim.

In the result, an AWARD is passed for Dismissal of the complaint.


Sd/-

(POONAM BODRA)

INSURANCE OMBUDSMAN


PROCEEDINGS OF








1. Name and Address of the complainant : Mr. Ajith A Punnasseril,

Punnasseril House, Thidanad P O, Kottayam, Pin-

686123

2. Policy Number

: 5001002819P111087388


: Ms. Akhila Rajan




: 28.12.2020




: --

8. Date of hearing

: 11.02.2021



: Mr. Ajith A Punnasseril (online)

b) For the Insurer : Ms. Pameela (online)

AWARD


2017. The complaint is regarding rejection of mediclaim. The complainant, Mr. Ajith A Punnasseril is

the policyholder.


The Complainant stated that he is working in Corporation Bank(Now Union Bank of India). He along

with his wife & mother is covered under Group Health Insurance Policy bearing

No.5001002819P111087388; Period of Insurance: 01/10/2019 to 30/09/2020; Sum Insured :

Rs.3,00,000/-. His wife was admitted in Mary Queens Mission Hospital, Kanjirappally for delivery of a

baby. The cashless claim for the mother is approved for Rs.20,000/- but the claim for the new born baby

was rejected. All the bills and supporting medical documents were submitted to the TPA by the hospital

hence now he is not in a position to claim for the reimbursement. The present complaint is for the claim

of his new born child, which the insurance company ought to have settled upto 3 months as per the

policy condition.

2. The Respondent Insurer entered appearance and filed a self contained note. It is submitted that as

per the information from the servicing TPA, The cashless approval was given for only Rs.20,000/- and the

documents related to the mother were accordingly shared by the hospital with the servicing TPA. The

bills and claim documents related to the new born child were not shared with the TPA. They are ready

to process the claim on the basis of terms and conditions of the policy on receipt of the claim for the

new born child along with the Discharge Certificate, Bills and Money receipt and all other relevant

treatment documents. As per their records, there is no reimbursement request received by the TPA

from the claimant/complainant. While resolving his grievance also the grievance team has informed

him to submit the required documents to the TPA for processing of the claim.

3. I heard the Complainant and the Respondent Insurer. The Complainant submitted that although the

cashless claim for the mother is approved for Rs.20,000/- but the claim for the new born baby was not

approved. All the bills and supporting medical documents were submitted to the TPA by the hospital

hence now he is not in a position to submit the reimbursement claim. The insurance company ought to

have settled upto 3 months of new born baby of the insured as per the policy condition of Group Health

Insurance policy issued to Indian Bank’s Association A/c Canara Bank. The Respondent Insurer submitted

that they are ready to settle the claim as and when all the relevant documents along with the original

bills pertains to the new baby was submitted. There was not reimbursement claim submitted by the

complainant insured to the TPA or to the respondent insurance company.

4. As per the Insurance Ombudsman Rules, 2017 Section 14. Manner in which complaint to be made. —

(3) No complaint to the Insurance Ombudsman shall lie unless—(ii) after receipt of decision of the

insurer which is not to the satisfaction of the complainant; Hence this complaint is not an entertainable

complaint as the insurance company grievance department responded positively to the complaint and

asked the complainant to submit the reimbursement claim pertains to the baby child along with the

original bills and relevant documents. The complainants should take maximum efforts to resolve their

issues/complaints with the insurance companies through their grievance redressal level itself before

coming to this forum. In this case the respondent insurer informed this forum that they are ready to

settle the claim as and when the respondent insured submit the reimbursement claim along with the

original bills and relevant documents. After hearing the complainant and the respondent insurer and

perusing the exhibits produced before the forum, I find it appropriate in the interest of justice to direct

the insurer to admit the claim after deducting the non payables subject to production of the original bills

and reimbursement claim form along with relevant documents.

In the result, an award is passed, directing the Respondent Insurer to pay an amount of Rs.4105/-,




Dated this the 19th day of March, 2021

Sd/-

(POONAM BODRA)

INSURANCE OMBUDSMAN


PROCEEDINGS OF









: Mr. Shibu John,

Kunnumpurathu, Vahuvadi, Thazhakara,

Mavelikara – 690102

2. Policy Number

: 1005002819P114534863


: Mr. Rahul S John




: 01.01.2021




: --

8. Date of hearing

: 04.03.2021



: Mr. Shibu John (online)

b) For the Insurer : Mr. Sureshkumar M K(online)

AWARD


2017. The complaint is regarding rejection of mediclaim. The complainant, Mr. Shibu John is the

policyholder.


The Complainant stated that for more than 5years, he is a policy holder of the health insurance of the

respondent insurer. His son`s claim was denied under policy exclusion clause 4.9 and the reason might

be the persons who had brought him to the hospital. To substantiate re-admissibility of the claim, he

send to the respondent insurer the first treated doctor`s certificate. The claim was rejected.

2. The Respondent Insurer entered appearance and filed a self contained note. It is submitted that an

accidental claim following a road accident of the complainant`s son on 10.7.20 , who was covered under

the group policy no.1005002819P114534863, issued to for the period 1.1.20 to 31.12.20, was denied

under policy exclusion clause 4.9(use of intoxication drugs/alcohol). As per the initial report of the

Doctor in the admission document of the District Hospital Mavelikara there was smell of alcohol (+) in

the breath of the patient.

3. I heard the Complainant and the Respondent Insurer. The Complainant submitted that his son fell

from bike and was admitted in the Sanjivini Hospital, Kollakadavu, for the period 10.7.20 to 13.7.20. The

claim when put up with the respondent insurer was denied stating policy exclusion clause 4.9, there was

smell of alcohol. The reason for smell of alcohol might be from the people who had brought his son to

the hospital. The Respondent Insurer submitted that the accidental hospitalization of the

complainant`s son for the period 10.7.20 to 13.7.20, after a fall from the bike, was denied under policy

exclusion clause 4.9(use of intoxication drugs/alcohol). As per the OP note at the district hospital, the

insured had smell of alcohol.

4. I heard the complainant and the respondent insurer and had gone through the records submitted. In

this case the claim where the complainant`s son aged 25years, covered under the group policy was

denied under policy exclusion clause 4.9, the arguments put forth by the respondent insurer were that:

i. the accidental hospitalization of the complainant`s son, 25 years old, was with a history of fall from

bike. ii. the initial report of the doctor in the admission document of the District Hospital Mavelikara

indicated smell of alcohol (+)in the breath of Patient . The claim was hence denied under policy

exclusion clause 4.9(use of intoxication drugs/alcohol); all stands admissible. I therefore do not want to

interfere in the decision of the respondent insurer in denying the claim



Sd/-

(POONAM BODRA)

INSURANCE OMBUDSMAN


PROCEEDINGS OF








1. Name and Address of the complainant : Mr. P K Jagadeesan

Ulamparambath House, Thiruvangoor P

O, Calicut-673304

2. Policy Number

: 2876/0019373/000003/000/00


: Mr. P K Jagadeesan


: Cholamandalam MS Gen. Insu.Co. Ltd


: 15.01.2021




: --

8. Date of hearing

: 11.02.2021


g) For the Complainant

: Mr. P K Jagadeesan (online)

h) For the Insurer : Dr.Minal Vinoth(online)

AWARD


2017. The complaint is regarding rejection of mediclaim. The complainant, Mr. P K Jagadeesan is the

policyholder.


The Complainant stated that he is policy holder of Cholamandalam General Insurance vide Policy

no.2878/0019373/000003/000/00 valid from 21st August 2019 renewed before due date. When he was

travelling in an Autorickshaw his head hit on top of Auto body part on 22/05/2020. With severe pain on

left shoulder and neck he has consulted with one Ortho specialist doctor and as advised by the doctor

consulted another Doctor at Meitra Hospital, Calicut and admitted their on 20/07/2020 and discharged

on next day 21/07/2020. The cashless facility was not approved by the respondent insurer hence

applied for reimbursement claim with all relevant documents. He has received a letter from the

respondent insurance company asking treated doctors certificate. He obtained the certificate from both

the treated doctors and sent the same to the insurance company. He contacted several times to the

insurance company personnel regarding the non settlement of the claim but finally the respondent

insurance company repudiated the claim through a letter dated 12/10/2020 quoting that the claim is

not admissible because the documents requested are not submitted. He believed that the relevant

documents to settle the claim were submitted but the insurance company repeatedly asking the same

queries and not settle the claim. The total relief sought is Rs.26,958/- (Hospitalisation – Rs.24,508/- +

OPD – Rs.450/- + Covid Test – Rs.2000/-).


subject mentioned policy is a group health Policy issued in the name of complainant Mr .JAGADEESHAN

for the period effective from 21/08/2019 to 20/08/2020 for sum insured of Rs300000 / which is subject

to terms , conditions and exclusions of the policy.

Upon submission of medical documents for re-imbursement of the medical expenses incurred towards

the diagnosis of frozen shoulder – left shoulder and its procedure, it was mentioned in the discharge

summary that he had type 2 diabetes mellitus and systemic hypertension and known case of DM ,HTN ,

COPD . Hence this respondent had send query letters dated 06/08/2020 , 23/08/2020 , 07/09/20

requesting the complainant to submit the treating doctors certificate confirming the exact duration of

the present ailment , first consultation paper and all past consultation paper , copy of indoor case

papers which contains complete details of treatment during hospitalization with treating doctors

certificate as to the history of comorbidity DM/HT/CAD with duration

This respondent had send repudiation letter vide dated 12/10/2020 as to closure of the claim due to the

non- submission of the deficiency documents

Post the receipt of this complaint, on perusal of the documents submitted along with the complaint

before this Hon’bleOmbudsman, it is specified in the certificates of treating doctors -Dr Parasanth G and

Dr Sameer Ali Paravath that complainant is a known case of type 2 diabetes mellitus and systemic

hypertension. The complainant has also produced a copy of the declaration that he was suffering from

asthmatic bronchitis last 10 years , hypertension last 5 years , DM last 4 years , which is also admitted in

his complaint

Hence for the above mentioned reasons, this respondent is not in a position to honour the claim. The

Claim is to be repudiated under non- disclosure and the reason for repudiation is mentioned herewith -.

On the perusal of document, the complainant is suffering from Bronchial Asthma 10 years,

Hypertension 5 years, Diabetic 4 years as per the history recorded in the submitted documents, this

information is not disclosed in the proposal form while proposing for insurance. In view of this non-

disclosure of material information, the contract of insurance becomes void and no claim is payable

under this policy.

Hence for the above mentioned reasons, the complaint is to be dismissed

Necessary supportive documents in respect of the claim are attached herewith for ready reference.

3. I heard the Complainant and the Respondent Insurer. The Complainant submitted that the accident

occurred when he was travelling in an autorickshaw on 22/05/2020. Admitted and treated at Meitra

Hospital, Calicut for left frozen shoulder as advised by two ortho specialist doctors. The respondent

insurance company repudiated the claim stating the reason of non submission of deficiency documents

asked for. The Respondent Insurer submitted that while processing the submitted claim, the company

asked to produce the treating doctors certificate confirming the exact duration of the present ailments

like DM, HTN, COPD and asmatic bronchitis. The complainant insured failed to produce the treating

doctors certificate confirming the exact duration of the present ailments, first consultation paper and all

past consultation papers and copy of the indoor case papers. The complainant is suffering from

Brochitis asthma 10 years, HTN 5 years, DM last 4 years, hence due to non-disclosure of material

information at the time of submission of proposal form, no claim is payable.

4. After hearing the complainant and the respondent insurer and perusing the exhibits produced before

the forum, this forum confirmed that in the policy schedule, bronchitis asthma is declared as pre-

existing disease. Also during the hearing the complainant insured submitted that despite all the pre-

existing diseases were disclosed at the time of submission of the proposal form, the company might

have omitted to enter it in the policy schedule. The respondent insurer failed to produce the proposal

form for verification to this forum. Hence I find it appropriate in the interest of justice to direct the

insurer to admit the claim on non standard basis and pay 50% of the assessed loss subject to terms and

conditions of the policy.

In the result, an award is passed, directing the Respondent Insurer to pay an amount of Rs.13479/-,




Dated this the 23rd day of March 2021.

Sd/-

(POONAM BODRA)

INSURANCE OMBUDSMAN


PROCEEDINGS OF









: Mrs. T Julie George

W/o George Anto, hirayath Kattumath

Veedu, P O Kodakara, Thrissur-680684

2. Policy Number

: 0150053000044637


: Mrs. T Julie George




: 21.12.2020




: --

8. Date of hearing

: 08.02.2021



: Mr. George Anto

b) For the Insurer : Ms. Hyma Soman

AWARD


2017. The complaint is regarding rejection of mediclaim. The complainant, Mrs. T Julie George is the

policyholder.


The Complainant aged 61 years stated that she had a fall in the bathroom on 12.9.20. On 14.09.20, she

got admitted in Apollo Hospital with severe back ache and walking difficulty and the doctor requested

for operation. She didn`t undergo operation but got discharged for fear of operation. Later an operation

was conducted and the expenses till 21.11.20 were Rs.3,48,237/-.


Complainant was issued with a SIB Suraksha Kavach Policy , for their account holders. The

hospitalization expenses were covered for Rs.1Lac. Policy period :1.4.20 to 31.3.21. The complaint

pertains to hospitalization after a fall in her bathroom on 12.9.20.Total claim expenses: Rs.3,48,237/- at

Apollo Adulux Hospital, Angamaly. The complainant claimed Rs.2lacs from the Oriental Ins. Co. Ltd. and

preferred for the balance claim amount. Admission period 14.9.20-18.9.20 & 5.10.20 to 14.10.20.

Diagnosis, L3-4 grade B stenosism L4-L5 grade degenerative listhesis with left radiculopathy and neuro

deficit, UTI,DM.The treatment availed was for urinary infection& advised stenosis. She had similar

complaint reportedly 3 years back. She was again admitted on 5.10.20 and underwent Lumbar Fusion

Surgery. The policy offers reimbursement for hospitalization following injury caused directly or solely

due to an accident. Secondly the hospitalisations were for PED treatment and not caused by the

accident.

3. I heard the Complainant and the Respondent Insurer. The Complainant represented by her relative

stated that she fell in the bathroom on 12.9.20, and with severe back ache and difficulty in walking was

admitted in Apollo Hospital from 14.9.20 to 18.9.20 & 5.10.20 to 14.10.20. The doctor adviced for

operation and it was conducted .The total expenses of Rs.3,48,237/-, when claimed was rejected. The

Respondent Insurer submitted that the policy provides reimbursement of medical expenses up to

Rs.1lac incurred for hospitalized treatment for any injury caused solely and directly by accidents. The

total amount spent was Rs.3,48,237/-. The complainant claimed Rs.2lacs from the Oriental Ins. Co. Ltd.

and preferred the balance claim amount from then respondent insurer. The admissions were 14.9.20-

18.9.20 & 5.10.20 to 14.10.20. Diagnosis, L3-4 grade B stenosism L4-L5 grade degenerative listhesis with

left radiculopathy and neuro deficit, UTI, DM. The treatment availed was for urinary infection & advised

stenosis. She had similar complaint reportedly 3 years back. The complainant was again admitted on

5.10.20 and underwent Lumbar Fusion Surgery. The claims were denied as the hospitalisations were for

PED treatment and not caused by the accident.

4. I heard the complainant`s representative and the respondent insurer and had gone through the

records submitted. In this case where the complainant aged 61years had an accidental fall in her

bathroom and had hospitalizations which were denied, the said PA policy offers reimbursement for

hospitalization following injury caused directly or solely due to an accident. Here, the complainant had

an accidental fall in the bathroom and that had caused her the injuries which forced her for

hospitalisation and surgery. Therefore on analyzing the situation and facts, the respondent insurer is

directed to pay the admissible amount to the complainant on submission of bills/records as per the

policy terms & conditions.

In the result, an award is passed, directing the Respondent Insurer to pay the admissible amount to the

complainant on submission of bills/records as per the policy terms & conditions, within the period

mentioned hereunder. No cost.



Dated this the 25TH day of March 2021.

Sd/-

(POONAM BODRA)

INSURANCE OMBUDSMAN


PROCEEDINGS OF









: Mr. SANIL SIDHIK

s/s Ali Chelapra House Marampilly PO

Aluva.

2. Policy Number

: 236000


: Mr. SANIL SIDHIK


: MAX BUPA HEALTH INSURANCE CO.LTD


: 27.01.2021




: --

8. Date of hearing : 15.03.2021



: Mr. Sanil Sidhik (online)

b) For the Insurer : Mr. Bhuvan Bhaskar (online)

AWARD


2017. The complaint is regarding rejection of mediclaim. The complainant, Mr. SANIL SIDHIK is the

policyholder.


The Complainant stated that he had taken a health insurance policy with Group Policy

No.00236000201800 through Federal Bank as a customer for himself and for his two children. In the

month of November 2018, he had submitted all the documents required to take the health insurance

policy from the respondent insurer. He had deposited insurance premium in his SB account No

19480100003816 at the Federal Bank Marampilly branch and informed the insurer.The respondent

insurer debited the premium amount of Rs.4959/- from his SB account only on 22.01.2019 and claims

that his insurance policy is effective from 11.02.2019, 20 days after this date. It was told that the

insurance came in to effect as soon as all the documents were handed over. But the respondent insurer/

Bank did not do as they had agrred . The complainant was admitted to Najat Hospital, Aluva on

11.02.2019 due to an accident to his right elbow and was discharged on 13.02.2019.. The treatment

costwas Rs.12369/-. However the respondent insurer rejected the claim. The reason given by the insurer

was that his insurance came in to effect on 11.02.2019. However in the month of November 2018, all

the relevant documents were handed over and he had signed the application and given the same to the

Bank.The respondnet insurer and the Bank deliberately delayed and there is no omission from the

complainant.

The complainant was not able to get the insurance claim due to the actions of the Bank and the

respondent insurer. It is clear that there had been a failure on the part of both the respondents in

serving him as a holder of insurance legally and morally. There should be an order dircting the

respondnet insurer/ Bank to pay him Rs.12369/-, which he had not received for the neglegence of the

obligations of the respondents and Rs.2 lakhs as compensation for the mental distress caused to him by

the respondents as a result of their actions.

2. The Respondent Insurer entered appearance and filed a self-contained note. It is submitted that at the very outset the Company denies all the averments and contentions made by the Complainant in the complaint except those, which are specifically adverted to and admitted herein. The Company further seeks leave of the Hon’ble Ombudsman to refer and rely upon the proposal form, policy documents with annexure, the correspondence exchanged between the Complainant and the Company along with all forms and declarations submitted by the Complainant, the relevant judgments of the Hon’ble Supreme Court and National Commission and any other relevant documents.

That contrary to the stand taken by the complainant, the company takes the opportunity to apprise the

Hon’ble Ombudsman of the fact that the policy holder had, after due deliberation and pondering over

the policy, submitted duly signed proposal form to the Company. The terms and conditions of the policy

are in strict adherence to norms set by IRDA and were duly communicated to the policy holder. The

Company has taken all the necessary precautions and has kept the policy holder adequately informed of

his policy terms and obligations.

That no cause of action has arisen in favor of the Complainant to file the present case, as the

hospitalization of the complainant falls before the policy issuance date hence in absence of active

coverage on the date of hospitalization the claim filed by the complainant was repudiated. It is relevant

to state herein that the complainant was enrolled in the Group Health Scheme on 11.02.2020 post

receipt of his application form on the same day and his hospitalization was from 10.02.2020 policy

holder has not adhered to the terms and conditions of the policy and has suppressed the material facts

about her actual health condition i.e as per prescription dated 20 Feb 2013 patient had history of

Obsessive compulsive disorder since 7-8 years, which was not disclosed during policy inception as per

the policy terms & condition this falls under material non-disclosure. Hence claim stands repudiated

under clause 12.20.

PRELIMINARY SUBMISSIONS AND FACTS:

That MR. SANIL SIDHIK(policy holder) submitted a Proposal Form proposing enrolment in Group

Health Insurance Policy to the respondent insurer to insure himself and his two daughters. The policy holder specifically proposed through the said proposal form to pay an annual regular premium. The Policy holder had signed and submitted the Proposal Form after going through the terms and conditions of the policy. The details of the Policy were also explained to him by the insurance agent/sales representative. It is pertinent to mention herein that the Policy holder had full knowledge of the terms and conditions of the Policy and only after going through the application for Insurance, thoroughly and properly, had signed the “Declaration” in the proposal form. On the basis of the Declaration made therein under, the Company has enrolled him with the master group policy NO. 00236000201800 with certificate of Insurance numbers allotted as per details mentioned below-

It is relevant to state herein that the total sum insured in the subject policy was to the tune of Rs. 2,00,000/- and the coverage was from 11.02.2019 to 10.02.2020. It is submitted that the company had sent the certificate of insurance to the complainant which had been duly received by him. It is submitted that the receipt of the aforesaid documents is not disputed by the policy holder which implies that the policy holder was in actual knowledge of the governing terms and conditions of the insurance policy and the same cannot be now refused at such later stage. That post issuance of policy a claim bearing No. 475671 was filed by the complainant for his

hospitalization at Najath Hospital for treatment of Supracondylar Fracture. The date of hospitalization was from 10.02.2019 to 13.02.2019 and the cost of treatment was Rs. 12,269/-. That after receipt of claim documents and investigation report, the respondent company scrutinized the claim documents carefully and repudiated the claim of the complainant on account of the fact that the hospitalization date was one day before policy issuance date i.e. start date of hospitalization was 10.02.2019 and risk commencement date was 11.02.2019. Relevant screenshot of discharge summary and COI has been placed below for ready refrence-

i

SUBMISSIONS ON NON-MAINTAINABILITY OF THE COMPLAINT:

It is submitted that the Complainant’s claim was rejected since the hospitalization was before policy

issuance date. In light of the above facts and circumstances, it is submitted that claim of the

Complainant has been repudiated rightly in accordance with the documents sub0mitted on record and

investigation report, hence, the present complaint being devoid of merits, may kindly be dismissed.

Moreover, the claim of the complainant needs to be strictly construed in the spirit of the terms of the

policy. It is a matter of common prudence that no one should be allowed to take advantage of her/her

own wrong.

3. I heard the Complainant and the Respondent Insurer. The Complainant submitted that he had taken

insurance from the respondent insurer through Federal Bank. The premium was deducted from the

Bank on 22.01.2019. But the policy issued is dated 11.02.2019. He met with an accident on 10.02.2019

and the claim was rejected by the insurer stating that the policy came in to effect with effect from

11.02.2019. During the hearing the insurer showed the proposal form to convince him that the date of

proposal, the complainant submitted that it is not his signature. The Respondent Insurer submitted that

they have issued group policy Federal Bank customers. The policy commencement date is 11.02.2019 .

The complainant had accident and was hospitalized on 10.02.2019, one day prior to the commencement

of the policy. As insurance coverage has not started, the respondent insurer has no liability

4. I heard the complainant and the respondent insurer and scrutinized the documents. The policy is a

Group policy issued through Federal Bank issued for a period from 11.02.2019 to 10.02.2020. The policy

commencement date is 11.02.2019 and the complainant was admitted in the hospital due to accident

on 10.02.2019 ie one day prior to the commencement of the policy.. The respondent insurer repudiated

the claim as there was no coverage as on the date of admission to the hospital. The complainant

submitted that Rs. 4959/- towards premium was debited from his account on 22.01.2019. Respondent

insurer has no role in the debit of amount form the account. The complainant has to approach the

Banking Ombudsman for the default of the Bank. The proposal form as shown by the respondent insurer

during the hearing was denied by the complainant stating that it is not his signature. In such a situation

the policy becomes null and void and as such the question of validity of the policy itself do not arise.



Sd/-

(POONAM BODRA)

INSURANCE OMBUDSMAN


PROCEEDINGS OF









: Mr. Antony J Thaliath

Thaliath House, Thiruvankulam,

Ernakulam-682305

2. Policy Number

: 110132028120000013


: Mr. Antony J Thaliath


: Reliance General Insurance Co. Ltd.


: 14.01.2021

6. Nature of complaint : Rejection of mediclaim


: --

8. Date of hearing

: 03.03.2021


i) For the Complainant

: Mr. Antony J Thaliath (online)

j) For the Insurer : Mr. Arun Chandy (online)

AWARD


2017. The complaint is Rejection of mediclaim. The complainant, Mr. Antony J Thaliath is the

policyholder.


The Complainant submitted that he was holding a policy with the respondent insurer bearing No.

110132028120000013. He was admitted in Lakeshore Hospital , Nettoor P O, Maradu on 20.10.2020 due

to Covid19. Hospitalization was advised as he had undergone valve replacement surgery (AVR25 3PIC

VALVE) in the year 02/04/2009. He was discharged on 29.10.2020. The claim for reimburseent was

submitted to the respondent insurer. The claim was repudiated and he received a letter on 01.12.2020.

He sent an appeal to the insurer on 04.02.2020 and a second appeal on 14.12.2020. It was rejected

pointing to the alleged mistake in procedure. Rs.16061/- was sanctioned upon denying the mistake in

procedure. Third appeal was filed on 30.12.2020 requesting to review the amount to the actual eligible

amount of Rs.1,46,645/-. It was also rejected . The complainant has requested to consider his complaint

and direct the respondent insurer to grand him his eligible amount.

2. The Respondent Insurer entered appearance and filed a self-contained note. It is submitted

that the Company has issued Group Mediclaim Insurance Policy bearing no.

110132028120000013 to Hindustan Organic Chemicals Limited and the risk was covered from

06-Jan-2020 to 05-Jan-2021, subject to Policy Terms and Conditions. As per Policy Terms and

Conditions, any non-medical charges are excluded under policy.. The relevant portion of the

Policy terms and conditions is mentioned below:

Section 3 Policy Exclusions:

The Company shall not be liable to make any payment for any claim directly or indirectly caused by,

based on, arising out of or howsoever attributable to any of the following:

16. Any non-medical charges as mentioned in "List of Medical Expenses Excluded" as appended.

The company has received the reimbursement claim from the Complainant. The subject claim lodged by the complainant was thoroughly scrutinized by the company on the basis of details and documents provided by the complainant and due investigation was also carried out by the Company in the matter. It was observed that the Complainant is admitted Covid-19 (Asymptomatic) on 20-Oct-2020 and discharged on 29-Oct-2020. We have received the final bills of Rs. 1,46,647/- After going through the bills which are admissible we have paid Rs.16062/- to the complainant on 28-Dec-2020 wide NEFT transaction No. 14480100053055 - FDRL0001448 – 2000848412.

Bill # Claimed Amount

Admissible amount

Non-Admissible amount

Non-Admissible reason

Miscellaneous charges

330.00 0.00 330.00 Rs.330- Deducted as admission charges are not payable

Investigation Charges

9160.00 1290.19 7869.81


1434.00 0.00 1434.00 Deducted as food charges not payable


1080.00 152.12 927.88

Professional fees charges

8400.00

1183.14

7216.86

Miscellaneous

charges

670.00

0.00

670.00

Deducted as food service and nutritional assessment not payable

Professional fees charges

12150.00

0.00

12150.00

Rs.12150- Deducted as isolation

charges not payable

Medicine &

Consumables charges

45098.00

3884.00

41214.00 Rs.475-Handrub, Rs.1061-

Hand wash, Rs.37348- Face mask, Cap disposable, Isolation gown, face shield, PPE kit not

payable


2370.00 333.81 2036.19


1220.00 171.84 1048.16

Room & Nursing Charges

63900.00

9000.00

54900.00

1K/DAY

Investigation 330.00 46.48 283.52

Charges


500.00 0.00 500.00 Deducted as MRD charges not payable


625.00 0.00 625.00 Rs.625- Deducted as per claim form

Total 147267.00 16061.58 131205.42

The Sum insured under the subject policy is Rs-100000/- The Room rent eligibility is 1% of Sum Insured as per the policy. But the complainant opted a room with rent cost of Rs-7,100/- per day (it include nursing charges also) hence the proportionate has been applied on the rest charges except medicine. Hence, the Respondent Insurance Company has settled the claim as per policy terms and conditions and made payment of Rs. Rs.16062/- to the complainant. Hence, there is no cause of action in the subject matter and the complaint deserves to be dismissed on this ground itself.

3. I heard the Complainant and the Respondent Insurer. The Complainant submitted that he got

admitted in Lakeshore Hospital, on 20.10.2020 due to Covid19. Hospitalization was advised as he had

undergone valve replacement surgery in the year 2009. He was discharged on 29.10.2020. The claim for

reimburseent was allowed only for a partial amount, which is not fair. The Respondent Insurer

submitted that the complainant was having a sum insured of Rs.1,00,000/-. The Room rent eligibility is

1% of Sum Insured as per the policy. But the complainant opted a room with rent cost of Rs-7,100/- per

day (it include nursing charges also) hence the proportionate has been applied on the rest charges

except medicine. Hence, the Respondent Insurance Company has settled the claim as per policy terms

and conditions and made payment of Rs. Rs.16062/-

4. On hearing both the parties and on scrutiny of the documents it is found that the complainant has

incurred an amount of Rs.7100/- per day towards Room rent and nursing charges whereas he is eligible

for only Rs.1000/- per day . As per policy terms and conditions, the complainant is eligible for only 1% of

the sum insured ie Rs.1000/-. Hence the proportionate charges has been applied on the rest charges

except medicine. The respondent insurer has rightly settled the claim and is justifiable.



Sd/-

(POONAM BODRA)

INSURANCE OMBUDSMAN

.


PROCEEDINGS OF






INSURANCE OMBUDSMAN, KOCHI



: Mr. Akash K V,

Vidya Academy of Science &

Technology, Thrissur

2. Policy Number

: 441100/48/2020/877


: Mr. Akash K V

4. Name of the Insurer : The Oriental Insurance Co. Ltd.


: 05.02.2021




: --

8. Date of hearing

: 19.03.2021



: Mr. Akash (online)

b) For the Insurer : Sri Sujith Krishnan (online)

AWARD


2017. The complaint is regarding rejection of mediclaim. The complainant, Mr. Akash K V is the

policyholder.


The Complainant stated that his claim under Group Mediclaim was rejected. He is a policy holder since

2016 when he was a B Tech student. He sought information regarding lasik surgery for correcting his eye

power and got a positive reply that he would get the claim. He got the surgery done in May 2020 . The

claim was rejected raising clause 4.1 , that his disease was pre existing. He submitted proof of Doctor’s

prescription dt. 13/11/2018 that his disorder was first observed then. He affirms that his disease is

neither pre existing nor from birth. He requests Ombudsman to sanction his claim.

2.The Respondent Insurer entered appearance and filed a self contained note. It is submitted that

Mr.Aakash was diagnosed to have Compound Myopic Astigmatism in both eyes . He was advised Topo

guided Lasik Treatment in Both Eyes and the same was done on28.05.2020 and discharged on the same

day.

As per the medical report it is observed that Mr. Aakash was suffering from this condition for past 3

years and he is having developmental myopis which manifested since past 3 years.

As per the Mediclaim Insurance Policy (Group) condition 4.1 ( Exclusions) , “The Company shall not be

liable to make any payment under this policy in respect of any expenses whatsoever incurred by any

Insured Person in connection with or in respect of:

4.1 Pre-existing health condition or disease or ailment / injuries : Any ailment / disease / injuries /health

condition which are pre-existing (treated / untreated, declared / not declared in the proposal form),

when the cover incepts for the first time are excluded upto 4 years of this policy being in force

continuously.’

There is no violation of our policy condition and under the above circumstances and the respondent

insurer submits that the stand in denying the claim be upheld and pray that the compliant may be

dismissed.

Besides, clause 4.6 of the policy excludes,

"Surgery for correction of eye-sight, cost of spectacles, contact lenses, hearing aids etc.

Since the treatment take is a procedure for correction for eyesight, the subject claim would not

become payable under the policy clause 4.6.

3. I heard the Complainant and the Respondent Insurer. The Complainant submitted that he hails from a

poor family and that he is pursuing his B.Tech, with the help of scholarship. He has the Insurance policy

since 2016. He developed weakness in eyesight in Nov, 2018 and based on the Ins. Agent’s advice, he

underwent Lasik surgery for correction of his eye power in 2020. The eye defect is neither pre existing

nor from birth. Yet, his claim was rejected quoting clause 4.1 of the policy. The complainant stated that

the Ins. Co. representative had mentioned to the students in front of the Principal and Finance Manager,

while canvassing the policy, that eye surgery is covered under the policy. The Respondent Insurer

submitted that initially the claim was repudiated under clause 4.1 but subsequently, when the Grievance

was taken with the Regional Office, the repudiation was done under Exclusion Clause 4.6.

4. I have heard both the sides and perused the documents. The Discharge Summary states that the

complainant was diagnosed with Compound Myopic Astigmatism in both eyes and Topo guided Lasik

treatment in both eyes.

It is observed that clause 4.6 of the Policy, excludes Surgery for correction of eye-sight. The

repudiation under this clause was communicated to the complainant by the Ins. Co. on 29/11/2020,

prior to the complainant lodging the complaint with this Forum. In any case, the claim is not tenable.

The complainant was asked to furnish MoU, if any, between the College and the Respondent Insurer

agreeing upon specific terms and conditions of the Policy covering Hospitalisation for Treatment

/Surgery for correction of eye-sight, but the complainant has not been able to. It is therefore inferred

that there is no agreement between the respondent insurer and the institution (where the complainant

is a student) about inclusion of hospitalization expenses for Surgery for correction of eye-sight in the

Group Policy



Sd/-

(POONAM BODRA)

INSURANCE OMBUDSMAN


PROCEEDINGS OF






INSURANCE OMBUDSMAN, KOCHI



: Mr. Sandeep S,

Pattath Enclave, Opp. Kochi Shipyard,

Ravipuram, M G Road-682015

2. Policy Number

: 124200/48/2019/004752


: Ms. Santhamma P


: The Oriental Insurance Co. Ltd.


: 12.12.2020




: --

8. Date of hearing

: 09.02.2021


k) For the Complainant

: Mr. Sandeep (online)

l) For the Insurer : Ms. Geetha Vijayan (online)

AWARD


2017. The complaint is regarding rejection of mediclaim. The complainant, Mr. Sandeep S is the

policyholder.


The Complainant stated that he is an employee of HDFC Life, Cochin, Kerala and had a medical

insurance cover as part of his employee eligibility. During Sept 2018, his mother was hospitalized at

Lakeshore Hospital, Cochin. When admitted, the hospital collected an initial deposit which they

promised to return once the final bill is settled. The final bill had a component that was approved by

MDINDIA and the rest was paid by him before his mother got discharged. When he contacted the

hospital for the refund, he was told the amount has not been settled by MD INDIA. He has been

contacting MD India since October 2018 regularly by calls and mails which are either not responded to

or stating that that they will do the needful soon. HDFC Life too has requested MD India to do the

needful and also highlighted this to Oriental Insurance multiple times but all the requests have been in

vain. Last month MD India assured but again their word wasn't kept. As a consumer he feels cheated and

left to beg MD India for releasing the approved amount to the hospital so that his refund would be

released.

Details: Insurance Company - Oriental Insurance Company

TPA - MD India

Patient Name - Late Santhamma P

Hospital Name - Lakeshore Hospital & Research Centre

Hospital City - Ernakulam

Claim Control Number - MDI4351508

IC Claim Number - 124200/48/2019/004752

Date of Admission - 03/08/2018

Date of Discharge - 18/09/2018

Date of Cashless Final Approval - 18/09/2018

Deposit amount pending with hospital - Rs 9500/-

He requests the Ombudsman to help in getting this claim paid at the earliest..

2. The Respondent Insurer entered appearance and filed a self contained note. It is submitted as follows :

Brief Underwriting details :

Policy Issuing Office : DADAR DIVISIONAL OFFICE, MUMBAI.

Type of Policy : TAILOR MADE GROUP MEDICLAIM INSURANCE POLICY

Insured : M/s. HDFC Standard Life Insurance Co.Ltd.

Insured Person : MR. SANDEEP S.

Patient : SANTHAMMA P.

Family Floater Sum Insured : Rs.4,00,000/-

Period of Insurance : 01.04.2018 to 31.03.2019

Brief Details of the Claim :

TPA Claim No. MDI4351508

Mrs. SANTHAMMA P was hospitalized at Lakeshore Hospital & Research Centre Ltd. from 30.08.2018 to

18.09.2018 for Carcinoma of Lung. Insured person is covered under TAILOR MADE GROUP MEDICLAIM

INSURANCE POLICY with family floater sum insured of Rs.4 lakh.

The claim of Insured person Mr. SANDEEP S. is under process and claim amount of Rs.1,20,594 payable

is as per below mentioned calculation:

Sr.

No.

Particulars Requested Amt. Deduction Amt. Reason Payable Amt.

1 Bed/Nursing Charges 57830 24080 Policy Term

&Condition [

Proportionate

deduction

41.6%]

33,750

2 Visit Charges 5050 3101 [ Proportionate

deduction

41.6%]

2,949

3 Investigations- Analysis 37090 15429 [ Proportionate

deduction

21,661

41.6%]

4 Procedure 19650 8174 [ Proportionate

deduction

41.6%]

11,476

5 Instrument/Monitor/Pulse 6670 2775 [ Proportionate

deduction

41.6%]

3,895

6 Medicines 93761 0 Actual 93,761

7 Others 5190 5190 Non- Payable

Alpha Bed,

Food,

Nutritional

0

8 – – 16749 Co-payment-

Delay in Claim

Intimation [As

per Policy

condition]

-16,749

9 – – 30149 20% Co

Payment

deduction is

applicable for

each and every

claim on

Payable amount

-30,149

TOTAL 2,25,241 1,04,647 1,20,594

.

3. I heard the Complainant and the Respondent Insurer. The Complainant submitted that

his mother was admitted to Lakeshore hospital in Sept. 2018. At the time of admission, he had

deposited an amount of Rs.9,500/- in the hospital. While the Ins. Co. paid cashless claim directly

to the hospital, the amount of Rs.9,500/- paid by him to the hospital was not refunded to him ,

despite several reminders during the past 3 yrs. , to the TPA and the Ins. Co.’s offices at Kochi

and at Mumbai, both by him as well as by his employer HDFC Life , the Group policy holder. The

Respondent Insurer submitted that the delay was on the part of the TPA. Cashless settlement

had been made with the hospital, following which the complainant/ insured had not submitted

reimbursement bills.

4. I have heard both the sides and perused the documents. The complainant had made an initial

deposit of Rs.9,500/- (on 30/8/2018 , the date of admission of his mother), and an amount of

Rs. 1,34,004/- on discharge. Cash Receipt for the latter is submitted now.

The Ins. Co. had Authorized Cashless facility on 3/9/2018 for Rs. 23,760/- and on 18/9/18 for

Rs. 96,834/-, ( totaling Rs.1,20,594/-) and paid to the hospital.

The balance Admissible Claim Amount is Rs. 47,473/-

For a Reimbursement Claim, an insured/ claimant has to submit Claim documents including

Claim Form to the Ins.Co./TPA, for processing the claim. The Ins. Co, has stated that the

complainant has not submitted Claim Form, besides KYC/Aadhar copy and PAN Card copy, Bank

details/Cancelled cheque leaf.

In the result, an award is passed, directing the Respondent Insurer to pay within the period mentioned

hereunder, an amount of Rs. 47,473/- , subject to the Complainant submitting the documents cited

above. No cost.




Sd/-

(POONAM BODRA)

INSURANCE OMBUDSMAN


PROCEEDINGS OF









: Mr. Ali Mohasin

Pathuvava House, Kayantikkara,

Muppathadom P.O, Aluva 683110

2. Policy Number

: 2891/00000001/000/00


: Mr. Ali Mohasin


: Cholamandalam MS Gen. Insu.Co. Ltd


: 19.01.2021




: --

8. Date of hearing

: 03.03.2021



: Mr. Ali Mohasin(online)

b) For the Insurer : Dr. Prabhu (online)

AWARD


2017. The complaint is regarding rejection of mediclaim. The complainant, Mr. Ali Mohasin is the

policyholder.


The Complainant submitted that he had taken a health policy from the respondent insurer with a sum

insured of Rs.5,00,000/-He went to hospital due to fever and when tested was found Covid positive and

Doctor advised him to be admitted. He was admitted in Renai Medicity, Palarivattom and found positive

on November 2020. The next day morning itself , he had intimated the insurance company. On 27th

Nov.2020, he was discharged from the hospital. He had submitted all the medical reports, Discharge

summary, Hospital bills, Adhar card , pan card and cancelled cheque at their office at ernakulam on

3.12.2020. As there was no response from their end he mailed them all the details again on 18.02.2020.

On January first week he received a repudiation letter dated 18.12.2020 sating thathis claim is denied.

Hence he has approached this forum for getting his claim amount.

2. The Respondent Insurer entered appearance and filed a self-contained note. It is submitted that the

subject mentioned policy is a Group Health Policy issued in the name of complainant Mr Ali Mohasin

for the period effective from 03/07/2020 to 02/07/2021 for sum insured of Rs 300000 / which is

subject to terms , conditions and exclusions of the policy.

The claimant was admitted to Renai Medi City Hospital from 21/11/2011 to 27/11/2020 for Covid -19

On Scrutiny of the claims documents submitted, we observe that the claim is not admissible for the

following reasons:

On perusal of the claim documents, it is observed that the member got admitted in the hospital for the

treatment of Covid 19 and enclosed documents suggest all member vitals are stable and as per MOHFW

guidelines member does not require hospitalisation and treatment can be done under Home

quarantine. No indemnity is available or payable which is outside the scope of policy coverage

Definition, which reads as " Medically necessary means any treatment, tests, medication, or stay in

hospital or part of a stay in hospital which is required for the medical management of the illness or

injury suffered by You; must not exceed the level of care necessary to provide safe, adequate and

appropriate medical care in scope, duration, or intensity; must confirm to the professional standards

widely accepted in international medical practice or by the medical community in India .In the absence

of any illness necessitating the hospitalization as specified in this coverage, the claim is inadmissible.

Thus the treatment given during the hospitalization period doesn’t warrant inpatient admission; Insured

medical condition was within normal limits and not requiring hospitalization as per Ministry of Health

Guidelines. The vitals were stable and admission not required hence the claim is inadmissible

The complainant was admitted in Renai Medi City Multi Super Speciality Hospital with complaints of

fever , sore throat and cough and diagnosed with Covid 19- Category –B. and the physical findings

mentioned in the discharge summary clearly mentions that vitals were stable and the treatment given

was only supportive treatment . On perusal of , medical records , It is understood that inpatient

hospitalisation is not justified as vitals were stable.The discharge summary will prove that there was no

active line of was treatment given to the complainant , hence the claim is inadmissible.

As per the Clinical Management Protocol issued by Ministry of Health , Government Of India, clause 7

states as to Clinical severity and assessment parameters where in it is explained the case of mild case of

clinical severity where in certain symptoms are mentioned therein and mentioned with management at

Home or covid centre . In the present case , as per the discharge summary itself , the complainant had

no such symptoms and could have managed at home quarantine. The claim form which was duly filled

by the treated doctor will also prove that there was no active line of treatment.

It is further submitted that Clause 10 (1) of Clinical Management Protocol issued by Ministry of Health,

Government Of India the states about management of mild cases . Patients with mild disease may

present to primary care /outpatient department, or detected during community outreach activities,

such as home visits or by telemedicine. The complainant had no symptoms or had no history of co-

morbidities. Even he had no symptoms of complications that should prompt urgent care. Thus this

respondent had rightly repudiated the claim and hence for the above mentioned reasons, the complaint

is to be dismissed

3. I heard the Complainant and the Respondent Insurer. The Complainant submitted that he went to

hospital due to fever and when tested was found Covid positive on November 2020 and got admitted

Renai Medicity, Palarivattom. The respondent insurer repudiated the claim stating that there is no active

line of treatment. He submitted that he had severe headache and breathing problem. The cashless

request was denied by the insurer and hence he got discharged from the hospital voluntarily as he had

to remit money in the hospital. The Respondent Insurer submitted that the member got admitted in

the hospital for the treatment of Covid 19 and his vitals are stable and as per Ministry of Health and

Family Welfare guidelines the inusred does not require hospitalisation and treatment can be done under

Home quarantine. In the hospital he was put to covid isolation room. As his vitals are stable there was

no active line of treatment given to him. He was treated with only oral tablets. . The complainant had

no symptoms or had no history of co-morbidities. Even he had no symptoms of complications that

should prompt urgent care. Hence the claim was repudiated.

4. On hearing the complainant and the respondent insurer and on scrutiny of the documents it is found

the complainant had only mild symptoms of Covid for which hospitalization was not required. His vitals

were normal. Even though the complainant claims to have fever, his temperature at the time of

admission was 98.6 F. As per the indoor case papers the complainant had no known morbidities. His CT

Thorax was normal. There was no active line of treatment given to the complainant except certain

tablets and vitamins. The complainant was shifted to covid isolation room. Government of Kerala vide

their notification from time to time has declared that asymptomatic patients are to be home

quarantined. Only for patients with serious issues are to be hospitalized. As such the respondent

insurer’s decision to repudiate the claim is justifiable.



Sd/-

(POONAM BODRA)

INSURANCE OMBUDSMAN


PROCEEDINGS OF









: Mr. M J Francis,

Arackal Marocky House, Kuttikattukara P.O,

Udyogamandal, Ernakulam 683501

2. Policy Number

: 2850/61621181/00/B00


: Ms Jelsa Kumari Mariat




: 21.12.2020




: --

8. Date of hearing

: 23.02.2021



: Mr. Tom (online)

b) For the Insurer : Dr. Ahmed (online)

AWARD


2017. The complaint is regarding rejection of mediclaim. The complainant, Mr. M J Francis is the

policyholder.


The Complainant stated that he and his wife are Sr. Citizens. He had taken the health policy through IOB,

Udyogamandal, Br. Ernakulam where he is a account holder. The policy inception was in 2013. At that

time his spouse had recovered from Ovarian Cancer which was declared. The complainant was informed

that the claims would be accepted post 4years of the disease, if there is a recurrence. The disease of his

spouse recurred in August 2020 and she had to undergo a surgery. Both cashless and reimbursement

were denied stating non declaration of PED. The Quantum of relief is Rs.2,67,500/-.


complainant obtained an IOB Health care plus policy which covers the period from 23.7.20 to 22.7.21.

The complainant`s spouse was hospitalized at the Rajagiri Hospital with abdominal pain and relapsed

Carcinoma Ovary from 10.9.20 to 19.9.20. As per the observations and documents submitted the

complainant`s spouse was having a history of C/o carcinoma ovary and underwent hysterectomy with

bilateral salpingo oophorectomy in 2011, which was not declared at the time of taking the policy. The

claim was therefore rejected as per Non disclosure clause.

3. I heard the Complainant and the Respondent Insurer. The Complainant submitted he and his spouse,

Sr. Citizens holding an IOB Health care plus policy which covered the period from 23.7.20 to 22.7.21, for

a sum insured of Rs.5lacs. At the time of the policy inception in 2013, his spouse had recovered from an

Ovarian Cancer which was declared. The complainant was then informed that the claims would be

accepted post 4years of the disease, if there is a recurrence. The policy was renewed till Sep. 2020

continuously without break. Due to the recurrence of the disease, the complainant`s spouse underwent

surgery on 11.9.20, at the Rajagiri Hospital, Kochi. The cashless claim forwarded was rejected stating

non declaration of pre existing disease. The complainant therefore requested for the back papers. As it

was not submitted after follow-ups, as advised by the respondent insurer`s local branch, the claim was

submitted with a self declaration confirming decleration of the said disease at the time of taking the

policy. However the claim got rejected. The Respondent Insurer submitted that the complainant`s

spouse was hospitalized for the period 10.9.20 to 19.9.20 at the Rajagiri Hospital, with abdominal pain

and relapsed Carcinoma Ovary. As per the documents submitted by the complainant, the insured

patient was having a history of Carcinoma Ovary and underwent hysterectomy with bilateral salphingo

oophorectomy in 2011 which was not declared at the time of taking the policy. The claim was rejected

as per Non Disclosure Clause.

4. I heard the complainant and the respondent insurer and had gone through the records submitted by

them.

In this case where the complainant argued that his spouse`s claim for the treatment of relapsed

Carcinoma was denied stating non disclosure of Carcinoma Ovary and hysterectomy with bilateral

salphingo oophorectomy in 2011, the complainant stated that it was declared during the policy

inception in 2013. For this purpose, his requests for the back papers were not attended to by the

respondent insurer. The complainant further stated that the cover was taken for future expenses that

may occur for the said disease.

The respondent insurer`s counter arguments were that the insured patient was having a history of

Carcinoma Ovary and underwent hysterectomy with bilateral salphingo oophorectomy in 2011. This was

not declared during the policy inception. The claim was hence rejected as per Non Disclosure Clause.

The complainant had stated that the policy was taken for the future expenses that may occur for the

disease as there was a high chance of recurrence of Cancer. It implies that the complainant had taken

the policy being well aware that the recurrence of the cancer had a high chance. Considering the above

facts the respondent insurer certainly would not have taken the policy knowing that cancer had a high

chance of recurrence.

During the hearing, the respondent insurer was directed to present a copy of the proposal form to this

office within 7-days, from the hearing date to substantiate their version of the argument. However the

same was not presented. Here the benefit of doubt must go to the complainant. Therefore on analyzing

the facts and the situation, the respondent insurer is directed to pay the admissible amount to the

complainant, on receipt of the bills/records subject to policy terms & conditions.

Head Amount

Claimed

Amount approved Amount

Deducted

Remarks

Room& Nursing

Charges

40537 40537 0 NA

OT Charges 9733 0 9733 Rs.9733 deducted as

equipment charges like

Cardiac Monitor, Steam

inhalation, DVT pump,

Syringe Pump etc. not

payable as per T & C

Medicine&

Consumable

charges

93589 63736 29853 Rs.29853/ Non payable

deducted like face shield,

Gown, Mask, Tegadram,

Gauze, Glove, Drape, Under

pad, Apron, Light handle

cover, Cleaner, Uro meter

Professional fees

charges

66079 65454 625 Rs.625/ deducted for

Dietician charges as per

policy T&C

Investigation

Charges

20069 20069 0 NA

Miscellaneous

charges

4693 0 4693 Rs.4693/ for food and

Beverage Charges is not

payable as per policy T&C

Pre

Hospitalisation

charges

39379 36209 3170 Rs.3170/- deducted as

Rs.650/- for registration fee

and Rs.2520/- deducted as

incurred bills prior to 30 days

from date of admission

Post

Hospitalisation

charges

2822 2822 0

228827(Rs.45765/-

for 20% co

payment on

admissible

amount)

48074/-

Total 276901 183062 93839

In the result, an award is passed, directing the Respondent Insurer to pay Rs.1,83,062/-within the

period mentioned hereunder. No cost.




Sd/-

(POONAM BODRA)

NSURANCE OMBUDSMAN

.


PROCEEDINGS OF









: Mr. P M Thomas,

Knanan Valley Adivaram P.O, Devalokam ,

Kottayam 686004

2. Policy Number

: 2850/61549611/00/B00


: Mrs. Achamma Chacko




: 20.01.2021




: --

8. Date of hearing

: 10.03.2021



: Mr. P M Thomas (online)

b) For the Insurer : Dr. Ahmed (online)

AWARD


2017. The complaint is regarding ejection of mediclaim. The complainant, Mr. P M Thomas is the

policyholder.


The Complainant stated that claim for treatment of his wife for asthma , was not settled. He requests

the Ombudsman’s intervention.


Insured obtained Online ‘IOB Health Care Plus’ which covers the period from 04/07/2019 to 03/07/2020.

Mrs Achamma Chacko was hospitalized for the period from 30/12/2019 to 05/01/2020 at Bharath

Hospital with bronchial pneumonia, asthama, DM on OHA, Hypertension.

As per mentioned observation and documents submitted by the insured was having history of DM since

20 years which has not been disclosed at the time of taking the policy. Hence the claim was rightly

rejected as per Non-Disclosure clause.

The policy was issued based on the information provided by IOB with declaration that none of the

proposed members are suffering with any Pre Existing Disease. Pursuant to the issuance of the Policy

which commenced from 04/07/2015, a letter was issued dated 09/07/2015 to the Insured Mr. P M

Thomas inter alia requesting the Insured to submit the proposal form which has been submitted at the

Bank and further had shared copy of fresh proposal form, to be submitted to respondent insurer within

15 days. The letter was sent to the Insured with a CC to Bank Branch. The fact that the Policy has been

issued to the Insured on the basis of information provided by the Bank, which also means that the Bank

has provided the information which has been submitted by the Insured for which the policy has been

issued with a remark “Pre Existing Disease Declared as “No”.

The treatment taken by the Insured has direct nexus with the Diabetes Mellitus, as the Final Diagnosis as

per Discharge Summary is Pneumonia, Asthma, DM, Hypertension. LVF is a cause for breathlessness and

directly related to Pre-existing hypertension.

Therefore it is humbly stated that the claim has been rightly considered and approved as per the policy

terms and conditions and Hon’ble Ombudsman may kindly dismiss the present complaint .

3. I heard the Complainant and the Respondent Insurer. The Complainant submitted that his wife had

asthma and she first took out-patient treatment. Later, she was admitted in hospital, from 5/1/2020.

She has been suffering from asthma since 2 yrs and Diabetes for 10 to 15 yrs. The proposal was signed

by him but filled in by the agent. The claim is for asthma, which is not related to Diabetes. The

Respondent Insurer submitted that the policy is from 2015. The patient’s medical history in Discharge

Summary states DM , HTN , LVF and the complainant is suffering from DM since 20 yrs. However the

same was not disclosed in the Proposal form .

4. I have heard both the sides and perused the documents . It is observed from the Discharge Summary

that the complainant’s wife has history of DM for 27 yrs. The fact that she has LVF, indicates previous

history of HTN. In the Proposal form, pre –existing disease is not disclosed.

Section E General Conditions 1. Disclosure of Information of the policy states, “ The policy shall be void

and all premium thereon shall be forfeited to the Company in the event of misrepresentation, mis-

description or non-disclosure of any material fact by the policy holder.”

The claim is therefore, not tenable.



Sd/-

(POONAM BODRA)

INSURANCE OMBUDSMAN


PROCEEDINGS OF









: Mrs. Jayasri M S,

Ambalappattu House, Thekkekudy Lane,

Rayonpuram P.O, Vallam, Perumbavoor,

Ernakulam 683543

2. Policy Number

: 1005062818P114028926


: Mr. A G Vasudevan




: 15.02.2021




: --

8. Date of hearing

: 17.03.2021



: Ms. Jayasri M S (online)

b) For the Insurer : Mr. Mathew K J(online)

AWARD


2017. The complaint is regarding rejection of mediclaim. The complainant, Mrs. Jayasri M S is the wife

of the policyholder.


The Complainant stated that claim submitted for getting the reimbursement of hospitalization

medical bills of her husband (Late A G Vasudevan) was repudiated by the respondent insurer

United India Insurance Company. The claim has been repudiated on the grounds that her late

husband was alcoholic and the liver disease is ethanol induced. The treating doctor, Gastro

entologist categorically and unequivocally states vide Letter dated 16/07/2019, that Late Mr.A G

Vasudevan is not alcoholic and his liver disease etiology is not ethanol induced. Her entire

family have been covered by the GMP of Rubber Board Employees welfare society and

respondent insurer United India Insurance since the year 2015. The insurer approved claims

under this policy for her late husband’s hospitalization for the same liver disease conditions on

previous occasions. She enclosed copies of all relevant documents viz., Policy copy, renewal

circular etc.


complaint is in connection with a claim on Group Mediclaim Policy No.1005062818P114028926 we

had issued to M/s Rubber Board Employees' Welfare Society covering members and their family for the

period 29/01/2019 to 28/01/2020.

Mrs.M S Jayasri's husband, Mr. A G Vasudevan- a known case of Chronic Lever Disease as per Discharge

summary was admitted in Amritha Institute of Medical Science & Research Centre, Kochi on

18/03/2019 for treatment of Hepatocellular Carcinoma , cirrhosis of the liver. As per Discharge

Summary he is a known case of these conditions. As per Indoor Case Papers of various hospitals verified

the patient is a chronic alcoholic and cause of his liver conditions is Alcoholic liver disease. The

investigations, diagnosis, treatment summary etc. emanating from the hospital records reveals the

hospitalization is mainly for liver disease. This could only be attributed to the patient's abuse of alcohol

as no other probable reason is discussed in the medical records for his present conditions leading to

hospitalization.

Hence it is very much evident that the treatment is related to use of alcohol which is expressly excluded

as per exclusion clause 4.9 of the policy No.1005062818P114028926 covering the complainant and her

family.

Our Regional Office Grievance Committee has reviewed this claim and scrutinized the records in detail.

After careful examination of various points, the committee has decided to uphold TPA decision ratified

by us. The complainant's allegation of inconsistency in the claim settlement process citing other

hospitalization and other medical opinion of some other doctor not related to this hospitalization is

irrelevant to this case and cannot be admitted.

So the respondent insurer would like to request the honorable Ombudsman to note that the claim was

rejected since the treatment was for an excluded health condition based on clause 4.9 of this particular

policy cited above.

Hence it is humbly submitted before the Honorable Insurance Ombudsman that the rejection of the

claim is based on valid grounds and pray that this respondent insurer be exonerated from the complaint

against before the honorable Insurance Ombudsman.

3. I heard the Complainant and the Respondent Insurer. The Complainant submitted that the claim for

reimbursement of hospitalization medical bills of her husband (Late A G Vasudevan) was repudiated by

the respondent insurance company for the reason that Late Vasudevan was a chronic alcoholic and the

liver disease is ethanol induced. The treatment underwent for his husband in this same hospital was

earlier approved by another TPA of the same insurance company. The pre-authorization letter issued by

the TPA has not mentioned any ethanol abuse. She had submitted a letter for reviewing the claim along

with a certificate issued from Amritha Institute of Medical Sciences stating that the patient Vasudevan is

a case of Cirrhosis of liver with portal hypertension and HCC. The Respondent Insurer submitted that

patient Late Vasudevan was a known case of Chronic Liver disease as per discharge summary. As per the

Indoor Case Papers of various hospitals verified the patient is a chronic alcoholic and cause of his liver

conditions is Alcoholic liver disease. The patient was admitted and treated at Rajagiri Hospital during

the period from 14/04/2017 to 21/04/2017 for chronic parenchymal liver disease and the claim was

rejected for the reason of ethanol abuse. The ICP and discharge summary of the admission and

treatment clearly indicates that the patient is chronic alcoholic.

4. After hearing both the Complainant and Respondent Insurer and perusing the exhibits produced

before the forum, I find that the cause of the liver conditions of the patient is ethanol induced and

therefore I find no reason to interfere with the decision of the insurer in repudiating the claim.



Sd/-

(POONAM BODRA)

INSURANCE OMBUDSMAN


PROCEEDINGS OF









: Mr. Sankaran N K

Naduparambil House, Peringottukara P

O, Thrissur - 680565

2. Policy Number

: 041100/28/18/P102461147


: Mr. Sankaran N K




: 13.01.2021




: --

8. Date of hearing

: 03.03.2021



: Consent given

b) For the Insurer : Ms. Hyma Soman (online)

AWARD


2017. The complaint is regarding rejection of mediclaim. The complainant, Mr. Sankaran N K is the

policyholder.


The Complainant submitted that he was a member of the New India Flexi floater Group Mediclaim

policy issued to the employees and dependents family members of M/s Steel Authority of India Ltd for

the period from 11.07.2019 to 10.07.2020. He was hospitalized with complaints of Cerebro vascular

disease, Acute ischemic stroke, Multiple infracts, CVD, Hypertension and Diabetes Mellitus at Sun

Medical and research centre from 11.07.2019 to 22.07.2019. He has incurred an amount of Rs.47,460/-.

The claim was repudiated by the respondent insurer stating that hospitalization was not required. Even

after so many communications, no action was taken in favor of the complainant. He had approached

SAIL Bhilai and the respondent insurer, but there was no response. Hence he has approached this forum

for resolution of his issue.

2. The Respondent Insurer entered appearance and filed a self-contained note. It is submitted that the

policy issued is New India Flexi floater Group Mediclaim policy numbered 3103003419400000001

covering the employees and dependent family members of M/s Steel Authority of India Ltd for the

period from 11.07.2019 to 10.07.2020.Te policy is subject to New India Flexi floater Group Mediclaim

policy clause. The complainant and family has a sum insured of 4 lakhs under the policy. The policy

provides protection against unforeseen hospital expenses cover to the insured as described in the

clause. The present claim arose out of expenses incurred by the complainant for the treatment of

cerebrovascular disease, Acute ischemic stroke, multiple infracts, CVD, Hypertension and Diabetes

Mellitus at Sun Medical and Research Centre, a unit of Trichur Heart Hospital Ltd from 11.07.2019 to

22.07.2019.

The claim was processed and was denied as the treatments availed did not warrant hospitalization. Not

satisfied with the decision, the complainant has represented to his forum.

In this regard it is submitted that the complainant, 84 years was admitted in the hospital with chief

complaints weakness in upper limb and abdominal pain since 5 days duration. Investigations were

suggestive of age related cerebral atrophy/multiple infracts. The patient was diagnosed as

cerebrovascular disease, Acute ischemic stroke, multiple infracts, CVD, Hypertension and Diabetes

Mellitus. During the hospitalization, the patient’s vitals were normal throughout hospitalization period

and hence admission is medically not justified. Patient was treated with oral medications only, patient’s

condition was not as critical to warrant hospitalization/intravenous medications. The treatment given to

the insured does not support the need for hospitalization, hence the claim is repudiated. In view of the

facts mentioned, it is submitted that the claim was processed and denied as per mutually agreed terms

of the policy and no further amount is admissible for the claim preferred as per the terms and

conditions of the policy issued.

3. The Complainant was absent. He had informed his inability to attend the hearing through online due

to various health issues. The Respondent Insurer submitted that Patient was treated with oral

medications only, patient’s condition was not as critical that he warranted any hospitalization.

Investigations were suggestive of age related cerebral atrophy/multiple infracts and hence the claim was

repudiated.

4. On scrutiny of the Discharge summary and other documents it is found that the 84 year old patient

was diagnosed with cerebrovascular disease, Acute ischemic stroke, Multiple infracts/frontoparietal

region, CAD,AF old CVD, systemic hypertension and Type II DM. The patient was presented with sudden

onset of weakness. MRI brain showed multiple acute infarcts (L) fronto parietal region. The patient was

treated with antiplatelets, anti hypertensives, anticoagulant and other supportive medicines. A patient

with 84 years and having various health issues as diagnosed cannot be treated without hospitalization.

The repudiation on the reason that hospitalization is not warranted is not justifiable.

In the result, an award is passed, directing the Respondent Insurer to pay an amount of Rs. 41737/-,





Sd/-

(POONAM BODRA)

INSURANCE OMBUDSMAN


PROCEEDINGS OF









: Mr. Xavier Biju M V

23/1258Appully House, Channiparambu,

Kadebhagam, Palluruthy-682006

2. Policy Number

: OG-20-9999-9960-00000022


: Mr. Xavier Biju M V


: Bajaj Allianz General Insc Co. Ltd.,


: 09.02.2021




: --

8. Date of hearing

: 17.03.2021


m) For the Complainant

: Mr. Xavier Biju M V (online)

n) For the Insurer : Ms. Ravindran Shingatte (Online)

AWARD


2017. The complaint is regarding rejection of mediclaim. The complainant, Mr. Xavier Biju M V is the

policyholder.


The Complainant stated that he has taken a Group Capital Cash policy through the intermediary Canara

Bank bearing policy no.OG-20-1602-6405-00001309; Master Policy No.OG-20-999-9960-00000022. A

claim bearing no.OC-21-1002-6405-00001554 was reported in this policy on 11/08/2020. The

respondent insurance company asked him to submit ITR(Internal Treatment Record), but the same was

not submitted by him hence the claim was repudiated by the insurance company. He is a fisherman and

not aware of these formalities and claim procedures.

2. The Respondent Insurer entered appearance and filed a self contained note. It is submitted that the issuance of policy to the petitioner is admitted. The Policy number: OG-20-9999-9960-00000022 Hospital Cash Insurance Policy in favour of the petitioner was issued subject to certain terms, conditions and limitation thereof.

1. This respondent company say and submits that the complainant availed a Group

Hospital Cash Policy No OG-20-9999-9960-00000022 having policy which is subjected to its terms, conditions and exclusions thereof.

2. It is submitted that the Insured was admitted in the hospital for Acute Gastroenteritis with Lower Respiratory Track Infection from 29th April 2020 to 4th May 2020. It is submitted that after scrutiny of documents the claim was processed and payment of Rs. 15000/- is paid to the Insured on 26th Feb 2021 and the UTR no is SIN00043Q0113306. (Annexed herewith is the Claim Processing sheet).

3. It is submitted that insured is eligible for daily allowance for each completed 24 hrs of

hospitalization in a non ICU unit is Rs.3000/- Current admission is of 5 days and so the

amount of Rs. 15000/- is paid as per terms and conditions of the policy.

4. Therefore, it is humbly prayed that this Hon’ble Ombudsman may be pleased to accept this self-contained notes and to dismiss the complaint with the cost of this Respondent.

3. I heard the Complainant and the Respondent Insurer. The Complainant submitted that he has taken a

Group Capital Cash policy through the Canara Bank. He was admitted in the Our Lady’s Hospital on

29/04/2020 and discharged on 04/05/2020 and the claim is partly settled. Not satisfied with the

settlement of the respondent insurer he approached this forum for getting the balance amount. The

Respondent Insurer submitted that the Group Capital Cash policy is a daily benefit policy. The

complainant insured is eligible to get Rs.3000/- per day of IP treatment as per the policy terms and

conditions of the policy. This claim is settled as per terms and conditions and paid an amount of

Rs.15000/- for 5 days admission.

4. After hearing the Complainant and the Respondent Insurer and perusing the exhibits produced

before the forum, I find that the Respondent Insurer has settled the claim well in compliance with the

terms and conditions of the policy issued to the complainant and paid the amount he is rightly entitled

to receive. Hence I find no reason to interfere in the decision of the Insurer.



(POONAM BODRA)

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATE OF WESTERN U.P. & UTTARAKHAND UNDER INSURANCE OMBUDSMAN RULES, 2017

OMBUDSMAN – SH. C.S. PRASAD CASE OF MR. ROBIN KUMAR V/S UNITED INDIA INSURANCE COMPANY LTD.

COMPLAIN REF. NO.: NOI-H-051-2021-0207 AWARD NO:

1. Name & Address of the Complainant Mr. Robin Kumar Village Ahamadpur, Post Jalalabad, Tehsil Shamli, Shamli, Uttar Pradesh-247772. Ph. No.07500969800

2. Policy No: Type of Policy Duration of policy/Policy period Sum Insured

5001002819P111086429 Group Health Insurance Policy 01.10.2019 to 30.09.2020 Rs.4,00,000/- (Maternity Capping of Rs.75,000/- for LSCS delivery)

3. Name of the Patient Name of the policyholder Name of the Insured

Ms. Vandana Preetam Mr. Robin Kumar Indian Bank’s Association (BOI)

4. Name of the insurer United India Insurance Company Limited


6. Reason for repudiation Required documents not submitted by the Complainant


8. Nature of complaint Group Mediclaim

9. Amount of Claim --


11. Amount of relief sought Nothing mentioned in Annex VI A

12. Complaint registered under IOB rules, 2017

13 (1)(b)

13. Date of hearing/place 10.03.2021 / NOIDA


a) For the Complainant Mr. Robin Kumar

b) For the insurer Ms. Pamela Pinto, Dy. Manager



17. Brief Facts of the Case:- Mr. Robin Kumar, the Complainant had taken Group Health

Insurance Policy No. 5001002819P111086429 for the period from 01.10.2019 to 30.09.2020 for S.I. Rs.4,00,000/- (Maternity Capping of Rs.75,000/- for LSCS delivery). The Group Mediclaim Policy was issued to Bank of India covering their Employees with their dependent members. The reimbursement of hospitalization bills were rejected by the Insurance Company. Aggrieved, he requested the Insurer including its GRO to reconsider the claim but failed to get any relief. Thereafter, he has preferred a complaint to this office for resolution of his grievance.

18. Cause of Complaint:-

a) Complainant’s argument:- Mr. Robin Kumar, the Complainant stated in his complaint that his wife’s caesarean delivery took place in the hospital. He has sent all original documents to the Company and attached the same to their Raksha TPA App. But they demanded printed bills from him. He replied them that printed bills facility was not available at the hospital. But they never settled his bill and rejected on that ground.

b) Insurers’ argument:- The Insurer in their SCN stated that

⮚ Mr. Robin Kumar (Employee Code : 178890) along with dependent member Mrs.

Vandana Preetam (Spouse) are included in the above-mentioned policy for S.I. of Rs.4,00,000/- (Maternity Capping of Rs. 75000 for LSCS delivery)

⮚ They have received the following Claim for payment :-

● Claim No. : 545432021021690 (Raksha TPA) ● Name of the patient : Mrs. Vandana Preetam ● Name of the Hospital : Mother & Child Hospital, Muzzafarnagar ● DOA - DOD : 15-3-2020 to 18-3-2020 ● Diagnosis : Pregnancy - LSCS ● Amount Claimed : Rs.33,883.00 ● Amount Settled : Repudiated under Clause 5.5 of the policy

⮚ From the Claim Documents submitted, it was observed that Original Discharge

Summary with signature and stamp of the Hospital – Mother & Child Hospital, Muzzafarnagar (as mentioned in Claim Form) has not been submitted. Letter & Reminder letters were sent on 24/7/20, 2/9/20 and 28/9/20 calling for the documents but the insured failed to submit the requirements. In view of the same, the claim was closed under Clause 5.5 of the policy.

Clause 5.5 states that: All supporting documents relating to the claim must be filed with TPA within 15 days from the date of discharge from the hospital. In case of post-hospitalization, treatment (limited to 90 days), all claim documents should be submitted within 7 days after completion of such treatment.

19) Reason for Registration of Complaint: - Rejection of Mediclaim 20) The following documents were placed for perusal.

a) Complaint copy b) Policy Copy c) SCN

21) Observations and Conclusion:- Both the parties appeared for personal hearing through

video call and reiterated their submissions. Mr. Robin Kumar, the Complainant reiterated that he had submitted all required documents and bills for claim of his wife. But, the claim was rejected by the Company due to non submission of bills. The Insurance Company reiterated that the complainant had not submitted the Original Discharge Summary with signature and stamp of the Hospital – Mother & Child Hospital, Muzzafarnagar (as mentioned in Claim Form) despite repeated letters & reminder dated 24/7/20, 2/9/20 and 28/9/20. The Complainant had submitted the hand written Discharge Slip of Dr. Indrani’ Nursing Home. However, his wife was admitted in the Mother & Child Hospital, Muzzafarnagar. In view of the same, the claim was closed on 04.01.2021 under Clause 5.5 of the policy which states that: All supporting documents relating to the claim must be filed with TPA within 15 days from the date of discharge from the hospital.

During the course of hearing, it was directed to the complainant for submission of the required documents to the Insurer. On receipt of above, the Company is ready to process and settle the claim as per terms & conditions of the policy.

I have examined the documents exhibited and oral submissions made by both the parties. The Complainant is directed to submit the required documents to the Insurer. The Insurance Company is directed to pay admissible claim to the Complainant within a month after the submission of the required documents.

AWARD

Taking into account the facts and circumstances of the case and the submissions made by both the parties during the course of hearing, the Complainant is directed to submit the required documents to the Insurer. The Insurance Company is directed to pay admissible claim to the Complainant after the submission of the required documents. The complaint is treated as disposed off accordingly.

22. The attention of the Complainant and the Insurer is hereby invited to the following provisions of Insurance Ombudsman Rules, 2017:

a) According to Rule 17(6) of Insurance Ombudsman Rules,2017, the insurer shall comply with the award within thirty days of the receipt of the award and intimate compliance of the same to the Ombudsman.

Place: Noida. C.S. PRASAD Dated: 15.03.2021 INSURANCE OMBUDSMAN (WESTERN U.P. & UTTARAKHAND)

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF WESTERN U.P. AND UTTARAKHAND

UNDER INSURANCE OMBUDSMAN RULES 2017 OMBUDSMAN – SHRI C.S. PRASAD

CASE OF MR. ANUJ KUMAR SHARMA V/S THE ROYAL SUNDARAM GENERAL INS. CO. LTD. COMPLAINT REF: NO: NOI-H-038-2021-0244

AWARD NO:

1. Name & Address of the Complainant Mr. Anuj Kumar Sharma, Vill Mohanpur, PO Khaad, Mohan Nagar Thana & Tehsil-Syana, Bulandshahr, UP-203412.


MIB0504158000102 Group Health Policy 01.02.2019 to 31.01.2020


Mr. Anuj Kumar Sharma Mahindra & Mahindra Financial Services Ltd.

4. Name of the insurer Royal Sundaram General Insurance Co. Ltd.



Gross discrepancies in claim documents


8. Nature of complaint Repudiation of Claim – Group Insurance Policy

9. Amount of Claim Rs.89,885/-

10. Date of Partial Settlement n.a.

11. Amount of relief sought Rs. 89,885/-

12. Complaint registered under IOB rules

13 (1) (b)

13. Date of hearing/place 12.03.2021 at Noida – Online hearing


For the Complainant Mr. Anuj Kumar Sharma, Self

For the insurer Mr. Dinakar Bysani, Deputy Manager & Dr. Ashok Kumar

15 Complaint how disposed Dismissed


17) Brief Facts of the Case: This complaint is filed by Mr. Anuj Kumar Sharma against M/s Royal Sundaram General Insurance for repudiation of his hospitalization claim.


Complainant’s argument: The complainant was covered under Group Health Insurance policy issued by Mahindra & Mahindra Finance Co. vide policy no. MIB0504158000102, which was renewed for the period from 01.02.2019 to 31.01.2020, for the sum insured of Rs. 1 lakh. The complainant was admitted to Vijay Shri Hospital, Bulandshahr on 04.12.2019 for high fever. He was discharged on 13.12.2019. The complainant submitted reimbursement claim bill to the insurance company for Rs.90,000/-. The insurance company repudiated the claim for the reason discrepancies were found in claim documents which was totally unauthentic. Insurers’ argument: The insurance company submitted their SCN dated 08.03.2021 wherein they submitted that the complainant had preferred a reimbursement claim for Rs. 89,885/- with respect to his hospitalization for Viral Fever and Hepatitis at VIJAY SHREE HOSPITAL for a period from 04.12.2019 to 13.12.2019. On receipt of the claim documents from the complainant, they had carried out third party investigation of the claim and found that there were various gross discrepancies in the medical records submitted by the complainant which made it a clear-cut case of misrepresentation and mis-description of medical records. The insurance company mentioned few of the glaring discrepancies found during third party investigation: -Patient was not aware about his admission and discharge date and timing as well. -Complaints of the patient did not match with complaints noted by the treating doctor, as per patient he did not have the complaints of loose motion, whereas internal case papers reveal that he complainant had loose motions. - Patient was not aware about treating doctor’s name as he mentioned Dr. Dheeraj in questioner but hospital authority confirmed it as Dr. S. K. Sharma. - No receipt book was shown by the hospital. -Patient confirmed only oxygen support in ICU as he was not aware about monitor, pulse rate checker and spo2 counter in ICU. -Patient was not aware about treating doctor visiting timing and per day visits during hospitalization as he did not filled answer of these questions. - No purchase invoice was provided by the pharmacy. - Patient was not aware with the frequency of vitals check - No OPD paper was provided neither shown by patient while he had consulted with doctor two times after discharged. - Patient confirms that his sputum, urine and ECG investigations were done in hospital but, as per the clinical notes of treating doctor it was nowhere advised for these investigations. - Charge for same investigations was also not mentioned in hospital bill. -Patient also confirmed that he had made the payment to USG centre, while USG bill charge was mentioned in hospital bill. The insurance company further submitted that, in light of aforesaid details and considering the facts that were revealed during the third party investigation, it was evident that hospitalization appears to be managed for the purpose of claiming benefit and the claimant had attempted to extract unlawful gains out of the policy, which clearly establishes as a clear cut case of mis-description and mis-representation. Hence they had rightly repudiated the claim and the same had been communicated to the complainant vide the repudiation letter dated 24.03.2020. They further submitted that, on representation of the complainant, they had revisited the claim and as it was evident that, the complainant had attempted to extract unlawful gains out of the policy by misrepresenting the medical records, it was reiterated by the respondent company to

the complainant about its inability to reconsider the claim vide a repudiation letter dated 26.08.20. 19) Reason for Registration of Complaint: - Repudiation of claim

20) The following documents were placed for perusal. a) Complaint letter b) Insurance Policy c) SCN d) Investigation report e) Discharge Summary

21) Observations and Conclusion: - The complainant and the representative of the insurance company were present for online hearing on 12.03.2021. The complainant stated he was admitted in Vijay Shree Hospital, Bulandshahar, due to high fever but the insurance company did not reimburse the claim. The insurance company reiterated that the independent investigator was appointed to investigate the case and as per his report, so many discrepancies were found in the medical records submitted by the complainant which made it a clear-cut case of misrepresentation and mis-description of medical records. The same were mentioned in their SCN. The patient was not able to reveal the name of treating doctor. During the course of hearing, the insurance company was questioned if they felt that it was a case of fraud,then why they did not file an FIR against the complainant for submission of fraudulent claim. The insurance company replied that they would file an FIR against the complainant and send a copy of the same to this Office.

The insurance company vide their email dated 16.03.2021 informed this Office that they had filed a police complaint against the complainant with the PS Bulandshahar on 15.03.2021 and sent a copy of the same to this Office.

On going through the documents exhibited and the oral submissions made by both the parties during the hearing, it was noted the insurance company repudiated the claim on the ground that the complainant had attempted to extract unlawful gains out of the policy by misrepresenting the medical records. Looking into the facts and circumstances, there are many discrepancies in the claim of the hospitalization of the complainant. In order to correctly establish the facts of the case, a detailed investigation needs to be conducted, which is beyond the jurisdiction of this Forum. The complainant is thus free to approach any other Civil Court which has the jurisdiction of such cases. Further, the insurance company has registered a police complaint against the complainant. In view of the circumstances, the case is dismissed.

RECOMMENDATION Taking into account the facts and circumstances of the case and the submissions made by both the parties, the insurance company has submitted that they have filed a police complaint against the complainant. In view of the circumstances, the case is dismissed.




CASE OF MR. SUNIL BADOLA V/S RELIANCE GENERAL INSURANCE CO. LTD. COMPLAINT REF: NO: NOI-H-035-2021-0232

AWARD NO:

1. Name & Address of the Complainant Mr. Sunil Badola, REP-Sector 128, Jaiprakash Associates Ltd., Sector 128, Noida, UP-201304.


130131928120000161 Group Mediclaim Insurance Policy 01.11.2019 to 31.10.2020


Mr.Sunil Badola M/s Jai Prakash Assocuates

4. Name of the insurer Reliance General Insurance Co. Ltd.

5. Date of Repudiation Not repudiated


Not repudiated


8. Nature of complaint – Group Mediclaim

Partial Payment of Claim


10. Amount of Partial Settlement Rs. 87,757/-



13 (1) (b)

13. Date of hearing/place 12.03.2020 at Noida


a) For the Complainant Mr. Sunil Badola, Self

b) For the insurer Mr. Unmesh Shukla & Dr Nithin Kumar Madigala

15 Complaint how disposed Settlement


17) Brief Facts of the Case: This complaint is filed by Mr. Sunil Badola against M/s Reliance

General Insurance Co. Ltd. for partial payment of his hospitalization claim.


a) Complainant’s argument: Mr. Sunil Badola was covered under Group Mediclaim Policy in the name of M/s Jai Prakash Associates, bearing policy no.130131928120000161 issued for the period from 01.11.2019 to 31.10.2020 by M/s Reliance General Insurance Co. Ltd. The complainant was diagnosed as COVID-19 positive hence admitted in Jeewan Anmol Hospital, Delhi, on 11.06.2020 and was discharged on 18.06.2020. He submitted claim bill for

reimbursement to the insurance company amounting to Rs. 1,79,127/- out of which the insurance company settled the claim for Rs. 87,757/- only. Rs.91,370/- was deducted as non admissible amount. The complainant had requested for payment of balance amount of claim paid by him.

b) Insurers’ argument: The insurance company in their SCN dated 09.03.2021 wherein they stated that the complainant had preferred a claim under the above mentioned policy. He preferred a claim of total bill amount of Rs.157241/- before the insurance company. The insurance company processed the claim and paid Rs.87757/- after the deductions as per the policy coverage and conditions of the policy. The insurance company stated that it was pertinent to mention that the insurance company, by mistake, had calculated the bills of medicines, twice and total of claimed amount was wrongly mentioned on the settlement letter as Rs.179127/- whereas the correct claimed amount of the complainant was Rs.157241/- as per final bill. The deductions from the final bill were done as per the policy terms and conditions and the deducted items along with amount and reason had been shown in the table below.

S. No

Amount Bill Reason Payable Reason

1 Rs.12000/-

medical care charges

Not payable

since we have paid the consultation and nursing charges , Medicare care bill will not payable as per policy

2 Rs.37500/- PPE Kit Charges Not payable As per NME list

3 Rs.280/- IV fixation Not payable As per NME list

4 Rs.231/- Oxygen mask Not payable As per NME list

5 Rs.1200/- examination gloves

Not payable As per NME list

6 Rs.918/- nebulisation mask Not payable As per NME list

7 Rs.400/- N95 Mask Not payable As per NME list

8 Rs.2800/- diet charges Not payable As per NME list

9 Rs.200/- admission charges


10 Rs.15000/- HIC/Bio Medical Waste charges


The insurance company had stated that they had paid Rs.87575/- as per the admissible amount under the policy and the items not payable were as per the NME list and Policy terms and Conditions.

19) Reason for Registration of Complaint: Partial payment of claim.

20) The following documents were placed for perusal. a) Complaint letter/Form VIA b) Claim settlement sheet c) Policy document

d) SCN

21) Observations and Conclusion: - The complainant and the representative of the insurance company were present for online hearing on 12.03.2021. The complainant stated that the insurance company partially settled his hospitalization claim. The insurance company reiterated that the claim was settled as per the terms, conditions and exclusions of the policy. During the discussion, the insurance company was asked to re-consider the claim and send their decision to this Office.

The insurance company vide their email dated 24.03.2021, expressed their willingness to settle the claim and offered to pay Rs. 53,341/- on the following heads, subject to submission of documents: Documents Required Amount to be paid

1. Covid Report required Rs. 2400/- 2. Blood Gas Report required Rs. 1400/- 3. Chest X Ray Report required Rs. 900/- 4. Break-up dated 18.6.2020 as per final bill required Rs.11141/- 5. PPE Kit Charges Rs. 37,500/-

Total Rs.53,341/- I have gone through the documents exhibited and the oral submissions made by both the parties during the hearing, and the offer of settlement of the insurance dated 24.03.2021 to pay an additional amount of Rs.53,341/-, which is just and appropriate to meet the ends of justice. I recommend that the insurance company settles the claim as per their offer letter for Rs.53,341/- subject to submission of the requisite documents.

The complaint is closed.

Recommendation

Taking into account the facts and circumstances of the case and the submissions made by both the parties, the insurance company has reconsidered the claim and offered to pay an additional amount of Rs.53,341/-, subject to submission of documents. The complaint is closed.

22. The attention of the Complainant and the Insurer is hereby invited to the following provisions of the insurance Ombudsman Rules 2017: As per Rule 16 (3) the insurer shall comply with the terms of the recommendation immediately but not later than fifteen days of the receipt of such recommendation, and inform the Ombudsman of its compliance.


PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATE OF WESTERN U.P. AND UTTARAKHAND UNDER INSURANCE OMBUDSMAN RULES 2017

OMBUDSMAN – SHRI C.S. PRASAD CASE OF MR. HARISH BHATT V/S THE NEW INDIA ASSURANCE COMPANY LTD.

COMPLAINT REF: NO: NOI-H-049-21-21-0255 AWARD NO:

1. Name & Address of the Complainant Mr. Harish Bhatt, H.No. 163, Anu Niwas, New Colony, Rishikul, Haridwar-Uttarakhand-249410.


34090034200400000005 New India Flexi Floater Group Mediclaim Policy 09.06.2020 to 08.06.2021


Mr. Harish Bhatt M/s Divya Pharmacy

4. Name of the insurer The New India Assurance Co. Ltd.


6. Reason for repudiation Not repudiated


8. Nature of complaint (group mediclaim)

Partial payment of claim


10. Amount and date of Partial Settlement

Rs.74,333/- on 30.11.2020

11. Amount of relief sought Rs. 1,00,000/- as per Annex. VI A


13 (1) (b)

13. Date of hearing/place 22.03.2021 – online hearing at Noida


a) For the Complainant Mr. Harish Bhatt, Self

b) For the insurer Dr. Pradeep Gupta, -9311986306,Vipul TPA and Mr. Raj Gopal, 9412070446 Haridwar DO



17) Brief Facts of the Case: This complaint is filed by Mr. Harish Bhatt against New India Assurance Co. for partial payment of his hospitalization claim.


Complainant’s argument: The complainant, an employee of Divya Pharmacy, was covered under New India Flexi Floater Group Mediclaim Policy taken by his employer. The policy no. was 34090034200400000005 was issued for the period from 09.06.2020 to 08.06.2021. The complainant fell ill on 15.09.2020 and was admitted in Himalayan Hospital Dehradun, on

25.09.2020 after diagnosed with COVID-19 positive. He was discharged on 06.10.2020. He submitted reimbursement claim for Rs.1,88,370/- with the TPA on 24.10.2020 but the insurance company paid only Rs.74,333/- to him.

He also incurred approx. Rs. 25000/- as post discharge expenses. The complainant further submitted that the Uttarakhand State government department of medical Heath & family welfare G.O. had notified Room Rent of patients on hospitalisation in private hospitals. He requested this Office for the balance payment of his claim. Insurers’ argument: The insurance company submitted their SCN dated 10.03.2021 wherein they stated that the compliant was hospitalized in Himalayan Hospital, Dehradun from 25/09/2020 to 06/10/2020 for COVID-19 treatment. He was diagnosed in the hospital as a case of Covid-19 Positive & Type-2 Diabetes Mellitus and treated for the same in the hospital. This hospital was network hospital providing cashless facility to the complainant. But the hospital did not provide the cashless facility as per the complainant’s statement and he had to pay the entire bill of his own. The complainant lodged reimbursement claim with the TPA for Rs. 1,88,370/-. The insurance company stated that the Uttarakhand State Government had fixed the rates to be charged by the hospitals for COVID-19 treatment. But, the hospital billed the complainant as per their own guidelines for the treatment of COVID-19. The General Insurance Council had also provided guidelines for the treatment of COVID-19 patients which were applicable to all the insurers including themselves.. Hence, the claim was processed as per policy terms and conditions by the TPA accordingly they had paid Rs.74,333/-. As per Group Mediclaim policy provisions, the room rent entitlement of the complainant was 1% of Sum insured. The S.I. was Rs. 4 lakhs, hence room rent came out to Rs. 4000/- per day. But the complainant opted for room rent @Rs.15,000/- per day and Rs. 11,000/- per day. Therefore, the room rent had been restricted to Rs.4000/- per day besides restricting payment of other

expenses in the same proportion as per the entitled room rent. The major disallowed amount was towards room rent entitlement i.e. Rs. 90,000/-.

19)Reason for Registration of Complaint: - Partial payment of claim.


a) Complaint letter b) Policy document c) SCN d) U.K.Govt. Guidelines e) GIC Guidelines

21) Observations & Conclusions: The complainant and the representatives of the insurance company were present for online hearing on 22.03.021. The complainant stated that he was admitted for treatment of COVID-19 after discussing his case with TPA who advised him to go for reimbursement of claim. The hospital charged bill as per the guidelines of Uttarakhand Govt. He paid the hospital bill by himself and filed reimbursement claim with the insurance company who paid only 40% of the claim. The insurance company reiterated that the hospital was a network hospital and if the complainant preferred for cashless approval, automatically the rates charged would be as per the policy sum insured. Instead, the complainant preferred for a reimbursement claim. The hospital charged the bill as per the Uttarakhand State Government’s notification for COVID-19 cases but the claim was settled according to the General Insurance Council guidelines on the treatment of COVID-19 patients, applicable to all the insurers. The IRDA provided that the reimbursements claims would be processed as per policy terms and conditions. For the sum insured of Rs.4 lakhs, the applicable room rent @1%

of the Sum Insured was 4000/- per day. The complainant voluntarily got himself admitted in a room @Rs.15,000/- per day and Rs. 11,000/- per day but the maximum payable amount worked out to be Rs.4000/- per day besides restricting payment of other expenses in the same proportion as per the entitled room rent.

Ongoing through the documents exhibited and the oral submissions made by the insurance company during the hearing, it is seen that the hospital, in question, was a network hospital, and if the complainant could have been opted for cashless authorization, the authorization would have been done as per the sum insured of the policy. But instead, he opted for a reimbursement claim. Even though the Uttrakhand Govt had notified the room rent capping day but the said Notification Ref. 1325/XXVII-I/20-01(19) 2020 dated 21.08.2020, addressed to All DMs and all CMOs, not to the insurance companies. The insurance companies are bound by the guidelines of IRDAI and General Insurance Council of India. The IRDAI in their Circular Ref. IRDAI/HLT/REG/CIR/01/01/2021 has communicated for ‘Reference Rates for COVID-19'' where they have directed that: “Reimbursement claims” under a health insurance policy shall be settled as per the terms and conditions of the respective policy contracts. Hence, the insurers shall honour all the health insurance claims as per the terms and conditions of the policy contract.” Insurance company has settled the claim as per the guidelines. It is beyond the scope of this forum to settle the dispute which has arisen because of the difference in guidelines of the two independent authorities of the land. There is no need to interfere with the decision of the Insurance Company.


AWARD

Taking into account the facts and circumstances of the case and the submissions made by both

the parties, there is no need to interfere with the decision of the Insurance Company.



PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATE OF WESTERN U.P. AND UTTARAKHAND UNDER INSURANCE OMBUDSMAN RULES 2017

OMBUDSMAN – SHRI C.S. PRASAD CASE OF MR. KRISHAN PAL SINGH V/S STAR HEALTH & ALLIED INS. CO. LTD.

COMPLAINT REF: NO: NOI-H-044-2021-0242 AWARD NO:

1. Name & Address of the Complainant Mr. Krishan Pal Singh, D-31, Sector 47, Noida, UP-201301.


P/161216/01/2021/000683 Star Group Health Insurance Policy-Gold (for Bank Customers) 16.06.2020 to 15.06.2021


Mr. Krishan Pal Singh M/s Punjab National Bank

4. Name of the insurer Star Health & Allied Insurance Co. Ltd.



Not repudiated


8. Nature of complaint (Group mediclaim)

Partial payment

9. Amount of Claim Rs. 235441/-

10. Amount of Partial Settlement Rs. 174908/-



13 (1) (b)

13. Date of hearing/place 22.03.2021 at Noida – online hearing


• For the Complainant Mr. Krishan Pal Singh, Self

• For the insurer Mr. Mantosh Kumar & Dr. Madhukar Pandey



17) Brief Facts of the Case: This complaint is filed by Mr. Krishan Pal Singh against M/s Star Health & Allied Insurance Co. Ltd. for partial payment of his hospitalization.


a) Complainant’s argument: The complainant and his spouse were covered under Star Group Health Insurance Policy-Gold bearing certificate no. P/161216/01/2021/000683, issued for the period from 16.06.2020 to 15.06.2021. This policy was issued to Punjab National Bank’s customers. The complainant was hospitalized in the ICU of JayPee Hospital, Noida, from 14.10.2020 to 22.10.2020 for the treatment of COVID-19. The hospitalization bill was Rs.2,35,441/- but the insurance company first approved Rs. 165408/- and later on approved Rs. 174908/- thereby deducted Rs. 60,533/- paid by him. He approached the grievance cell of the

insurance company also but they also rejected his request to reimburse the deducted claim amount. . The complainant raised his queries for the deductions as under: 1. They allowed Plasma Therapy but did not allow the donor procedure charges. 2. The deductions towards the medicine Ulinastatin were related to experimental therapy/unproven as per AIIMS clinical management protocol. 3. Deduction for “Covifor restricted” for Rs. 2800/-. It was a restricted drug which was injected to him under the supervision of doctors. 4. They deducted Rs. 3000/- for consultation charges as per Covid-19 package. b) Insurers’ argument: The insurance company submitted their SCN dated 19.03.2021 wherein they stated that the was admitted on 14/10/2020 in Jaypee Hospital - Noida and discharged on 22/10/2020.As per Discharge Summary the insured was diagnosed with :

● COVID-I9 Infection ● Type 2 Diabetes mellitus ● Essential Hypertension

The complainant reported the claim in the 4th month of the Policy. He submitted a Pre authorization request for cashless treatment on 20/10/2020 and the same was initially approved for a sum of Rs. 25,000/-. Subsequently, on submission of additional documents along with the request for enhancement of the preauthorisation, a sum of Rs. 1,74,908/- approved and settled to the treating hospital vide NEFT Transaction no. N311201299994047 dated 06/11/2020. The complainant submitted a claim for reimbursement of medical expenses on 29/01/2021. A sum of Rs. 9,500/- was approved and settled to the insured vide NEFT Transaction No. N065211430194201 dated 06/03/2021. Deductions: Hospitalisation Expenses:-

● Rs. 3,000/- was deducted towards Professional Fees (Surgeon, Anesthetist, Consultation Charges etc) as the same forms a part of the Package charges treatment of COVID.

● Under the Package Charge, Plasma therapy charge was allowed, but donor procedure

charges were not payable. The Ulinastatin and Covifor were not payable as per Exclusion No. 16 of the policy, since both the medicines were not the recommended treatment by the guidelines from All India Institute of Medical Sciences, New Delhi and Ministry of Health And Family Welfare, Government of India regarding treatment of COVID-19 patients. Hence, a sum of Rs. 56,783/- was deducted from the Package Charges.

● Rs. 750/- was deducted towards others charges as medical record charges not payable

as per Other Excluded Expenses of the policy.

As per the Exclusion No. 16 of the Policy, “The Company shall not be liable to make any payments under this policy in respect of any expenses what so ever incurred by the insured person in connection with or in respect of Naturopathy Treatment, unconventional, untested, unproven, experimental therapies”. As per Coverage 1(a) of the Policy, “That if during the period stated in the Schedule / Certificate, the insured person shall contract any disease or suffer from any illness or sustain bodily injury through accident and if such disease or injury shall require the insured Person/s, upon the advice of a duly Qualified Physician/Medical Specialist /Medical Practitioner or of duly Qualified Surgeon to incur Hospitalization expenses for medical/surgical treatment at any Nursing Home / Hospital in India as an in-patient, the Company will pay to the Insured Person/s the amount of such expenses as are reasonably and necessarily incurred up-to the limits mentioned in the

schedule but not exceeding the sum insured stated in the schedule / certificate hereto”. The maximum amount was already settled to the Insured as per the Terms and Conditions of the policy, there was no further amount liable for payment under the policy for the present claim.

19) Reason for Registration of Complaint: - Repudiation of claim. 20) The following documents were placed for perusal.

a) Complaint letter b) Discharge Summary c) Policy document d) SCN 21) Observations and Conclusion: - The complainant and the representatives of the insurance company were present for online hearing on 22.03.021. The complainant stated that the insurance company did not pay the donor procedure charges, medicine Ulinastatin, Covifor and Rs.3000/- for consultation charges. The insurance company reiterated that they had settled the claim as per the terms and conditions of the policy. Ongoing through the documents exhibited and the oral submissions made by both the parties during the hearing, it is noted that the insurance company had additionally paid Rs.9500/- to the complainant on 06.03.2021. The deduction of Rs.3000/- for Professional Fees as the same was included in the package and deduction for plasma donor procedure charges were deducted as per the policy terms and conditions. Rs. 750/- was not payable as per Other Excluded Expenses of the policy. I see that the insurance company had settled the claim as per the terms and conditions of the policy; hence, I see no reason to interfere with the decision of the insurance company.


AWARD

Taking into account the facts and circumstances of the case and the submissions made by both the parties, I see that the insurance company had settled the claim as per the terms and conditions of the policy; hence, I see no reason to interfere with the decision of the insurance company.



PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATE OF WESTERN U.P AND UTTARAKHAND UNDER THE INSURANCE OMBUDSMAN RULES, 2017

OMBUDSMAN – SH. C.S. PRASAD CASE OF SH. NAVIN SAHU V/S. ICICI LOMBARD GEN. INS. CO.

COMPLAINT REF. NO.: NOI- H- 020- 2021 - 0203 AWARD NO:

1. Name & Address of the Complainant Sh. Navin Sahu A9-902, Casa Greens-1 Greater Noida (West) GH-04 A, Sector -16, G. Noida, Gautam Budh Nagar, Uttar Pradesh-201308. Ph. No.09545454090


4016/X/188235995/00/000 Group Health (Floater) Insurance Policy 07.12.2019 to 06.12.2020


Ms. Sonam Sahu Sh. Navin Sahu

4. Name of the insurer ICICI Lombard Gen. Insurance


6. Reason for repudiation Hospitalization is less than 24 hours


8. Nature of complaint Group Mediclaim

9. Amount of Claim N.A.

10. Date of Partial Settlement N.A.

11. Amount of relief sought Rs.32,999/-+Post hospitalization Approx. Rs.25,000/- as per Annexure VI A

12. Complaint registered under IOB Rules, 2017

13 (1) B

13. Date of hearing/place 24.03.2021 /Noida


a) For the Complainant Sh. Navin Sahu

b) For the insurer Ms. Terry Nambiar- Manager- Legal



17) Brief Facts of the Case : Sh. Navin Sahu, the complainant had taken Group Health (Floater)

Insurance Policy No.4016/X/188235995/00/000 commencing from 07.12.2019 to 06.12.2020 was issued to the complainant. He had filed claim reimbursement request for treatment of his wife Ms. Sonam Sahu. The Insurance Company rejected his claim due to hospitalization was less than 24 hours. Aggrieved, he requested the insurer including its GRO to reconsider the claim but failed to get any relief. Thereafter, he has preferred a complaint to this office for resolution of his grievance.


a) Complainants argument : The Complainant Sh. Navin Sahu stated in his complaint that with reference to Claim no. 220201970053-3, the claim was submitted to ICICI Lombard on 24th Sep 2020. After the verification from ICICI side, Rs.11, 928/- was deducted against the claim amount 22,454/-. He had continuous follow-up with the customer representative for the claim deduction but he does not have any positive response from their side. He had provided a clarification to ICICI from the treating doctor also. Claim No. 220202019010, claim was submitted to ICICI Lombard on 24th Sep 2020. The Claim was rejected due to hospitalization is less than 24 hours, (DOA-18-SEP-2020 05.25pm to DOD 19-SEP-2020 03.20 pm). However, they physically present more than 24 hours in hospital. Against this rejection, he had submitted revised discharge summary and reclaimed 220202032419. Again it was rejected for the same reason.

b) Insu

rers’ argument: The Insurer stated in their SCN that :

The Company would like to submit that CLYDE BERGEMANN INDIA PRIVATE LIMITED (herein after called as Master Policyholder) had opted for Group Health (Floater) Insurance Policy on December9, 2019 and it is valid till December 8, 2020 and the policy no.4016/X/188235995/00/000 covering the employees of Master Policyholder. With this regard, the Master Policyholder had paid the premium amount and opted for the Sum Insured as mentioned in the policy certificate.

The Master Policyholder agreed upon the terms and conditions and opted for the policy and paid the premium amount to the Company. It is pertinent to note that the Master policy holder had opted for the policy on December 9, 2019 after understanding the terms and conditions. After issuance of the policy, the policy documents were shared it with master policy holder and further the master policy holder’s responsibility and duty to share it with his employees. The Company understands that the Master policyholder must have shared it with all his employees. They would like to highlight the clauses as per the policy wording which are as follows:-

Coverage’s:-

21. Hospitalisation means admission in a Hospital for a minimum period of 24 in patient Care consecutive hours except for specified Procedures/Treatments, where such admission could be for a period of less than 24 consecutive hours.

44. Post Hospitalization Medical Expenses means medical expenses incurred immediately after the Insured Person is discharged from the hospital provided that:

(i) Such Medical Expenses are incurred for the same condition for which the Insured Person's Hospitalisation was required, and

(ii) The In-patient Hospitalization claim for such Hospitalization is admissible by the Insurance Company.

45. Pre Hospitalisation Medical Expenses means medical expenses incurred immediately

before the Insured Person is hospitalized provided that: (i) Such Medical Expenses are incurred for the same condition for which the Insured

Person's Hospitalisation was required, and

(ii) The In-patient Hospitalization claim for such Hospitalization is admissible by the Insurance Company.

The complainant i.e. Employee of Master Policyholder had submitted the cashless claim Intimation directly from the Felix Healthcare Pvt. Ltd (herein after called as ‘Hospital’) for the hospitalization from July 14, 2020 to July 17, 2020 of Complainant’s wife Ms. Sonam Sahu who was diagnosed with acute retention of Urine.

● With this regard the Company registered the claim and gave the claim intimation no. 220201970053.

● After receipt of the complete set of documents from the Hospital, wherein the Hospital had raised the claim amount of Rs. 31,255/- from which they have released the claim amount of Rs.25,820/- after the mandatory deduction as per the policy terms and conditions.

In the month of September, 2020 the Complainant had submitted the claim reimbursement form for the above hospitalization (i.e. Felix Healthcare Pvt Ltd) from July 14, 2020 to July 17, 2020 and the Complainant was claiming for Pre-Post Hospitalisation:-

● As this was of the same hospitalisation therefore they have provided the Claim No.220201970053-2.

● Further the Complainant himself had given the detailed claimed amount list.

● After receipt of the claim intimation form and the invoice copies from the Complainant, the company verified the bills and found out that the complainant had submitted the bills from of which few pertaining to the above hospitalisation and for the diagnosed with acute retention of Urine.

● But remaining are not pertaining to the actual hospitalisation and they are from the different hospital or from the clinic which are not pertaining to the actual hospitalisation wherein the policy terms and conditions clearly talks about Pre-Post hospitalisation should be related to the actual hospitalisation.

It is pertaining to note that on September 30, 2020 the Complainant had submitted another claim intimation form for the different hospitalisation and the admission dated September 18, 2020 at 17.25 and was discharged on September 19, 2020 at 15.20 (i.e. hospitalisation is less than 24 hour) at Motherland Hospital (herein after called as Hospital) and company intimated the clam and provided the claim no. 220202019010.

● Please refer the below print screen of the same for ready reference.

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Along with claim intimation form, they have received the discharge summary wherein it is clearly mentioned that the hospitalisation on September 18, 2020 at 5.25 pm and was discharged on September 19, 2020 at 3.20 pm, hospitalisation is less than 24 hours. They would like to retrieve the discharge summary as follows:-

,

Further in the final paid receipt and the final bill clearly says that the discharged on September 19, 2020 at 3.20 pm.

After reviewing the claim form, discharge summary and the final bill and with the available documents the Company came to the conclusion that there was less than 24 hours hospitalisation. Therefore, the Company repudiated the claim no. 220202019010 as per the policy’s terms and conditions.

It is pertaining to note that once again the claim was intimated to the Company after the repudiation of the claim no. 220202019010 for the same hospitalisation i.e. Motherland Hospital. After receipt of the claim intimation the company provided the new claim no. 220202032419 to the Complainant. The Complainant submitted the same documents of Mother land Hospital as mentioned above. After reviving the documents the claim was repudiated on October 30, 2020.

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They would like to state that 1st claim 220201970053 of the complainant was already paid to the Hospital. Claim under claim no. 220201970053- 2 for remaining pre hospitalisation and post-hospitalisation was paid to the Complainant as per the policy terms and conditions but in the settlement letter they have clearly mentioned that Dr. Lal path Lab of Rs.1,300/- for the injection and Glory Hospital of Rs. 2,100 and Rs. 700/-, the Complainant not provided any proof stating that the medical expenses for the said treatment was of taken for the same ailment or for the actual hospitalisation. If the Complaiannt will submit the proof than the claim will be released as per the policy terms and conditions. Further the Complainant raised the 2nd and 3rd claim no. 220202019010 and 220202032419which was repudiated because the hospitalization was less than 24 hours as submitted by the documents the said claim is not payable as per the policy terms and conditions.

It is pertaining to note that the complainant is alleging in the complaint copy that he was physically present at the hospital for more than 24 hours. But all the hospital documents which are available with them are stating that the complainant’s wife was admitted for less than 24 hours. They deny the fact, the Complainant is stating in the complaint copy.

In the light of above submissions, it is therefore submitted that the 1stclaim is already paid as per the policy terms and conditions and 2nd and 3rd claim is not payable as per the policy terms and conditions.

19) Reason for Registration of Complaint:- Rejection of Mediclaim

20) The following documents were placed for perusal:- a) Complaint Copy b) Policy with terms and conditions. c) Rejection letter. d) SCN

21) Observations and Conclusion :- Both the parties appeared for personal hearing through video call and reiterated their submissions. The Complainant Sh. Navin Sahu reiterated that he has submitted his first claim to the Insurer which has been settled by the Insurer but after the deduction of certain amount. Thereafter, the second Claim bearing No. 220202019010 was submitted to ICICI Lombard on 24th Sep 2020. This Claim was rejected due to hospitalization being less than 24 hours, (DOA-18-SEP-2020 05.25 pm to DOD 19-SEP-2020 03.20 pm). However, they were physically present for more than 24 hours in hospital. Against this rejection, he has submitted revised discharge summary and reclaimed 220202032419. Again it was rejected for the same reason. The Insurance Company reiterated that first Claim was paid to the Complainant as per the policy terms and conditions. In the settlement letter, they have clearly mentioned that Dr. Lal path Lab of Rs.1,300/- for the injection and Glory Hospital of Rs. 2,100 and Rs.700/-, the Complainant not provided any proof stating that the medical expenses for the said treatment was of taken for the same ailment or for the actual hospitalisation. If the Complainant will submit the proof, then they are ready to release the amount as per the policy terms and conditions. Further the Complainant raised the 2nd and 3rd claim no. 220202019010 and 220202032419 which was repudiated because the hospitalization was less than 24 hours and the same is not admissible as per the policy terms and conditions. All the hospital documents which are available with them reveal that the complainant’s wife was admitted for less than 24 hours. Even in the claim form which was duly filled and signed by the complainant himself, the period was less than 24 hours. Hence, the 2nd and 3rd claim are not payable as per the policy terms and conditions.

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During the course of hearing, it was directed to the complainant to submit an Affidavit issued by the Treating Hospital regarding correction that “the hospitalization period is more than the 24 hours”. The complainant has submitted a simple declaration on the letter head of the Motherland Hospital dated 27.03.2021 to the Ombudsman office on 27.03.2021. Ongoing through the documents exhibited and the oral submissions made by both the parties, it is observed that the complainant has submitted the simple declaration on the letter head of the Motherland Hospital dated 27.03.2021 which was neither signed and stamped by the authorized person of the hospital nor it was an Affidavit as directed during the course of hearing. It is observed that the Complainant did not submit an Affidavit and only misrepresented the facts to the Insurance Company and the Ombudsman Office. Even the Hospital’s statement is not supported by any Affidavit. The claim papers have many discrepancies regarding period of hospitalization for more than 24 hours. The Insurer has reasonable grounds to reject the claim as per terms and conditions of the policy. Hence, I see no reason to intervene in the decision. The complaint is dismissed.

AWARD

Taking into account the facts and circumstances of the case and the submissions made by both the parties during the course of hearing, I see no reason to intervene in the decision.

The complaint is dismissed.




CASE OF MR. DAVENDER SINGHAL V/S STAR HEALTH & ALLIED INS. CO. LTD. COMPLAINT REF: NO: NOI-H-044-2021-0245

AWARD NO:

1. Name & Address of the Complainant Mr. Davender Singhal, C/o Satish Chand Singhal, Kirana Merchant, Main Bazar, Muradnagar,

Ghaziabad, UP-201206.


P/161212/01/2019/017053 Family Health Optima Insurance Plan 07-02-2019 to 06-02-2020


Mr. Davender Singhal Mr. DevenderSinghal

4. Name of the insurer Star Health & Allied Insurance Co. Ltd.



Condition No. 6 : Misrepresentation of material facts


8. Nature of complaint (Group mediclaim)

Repudiation


10. Amount of Partial Settlement Nil



13 (1) (b)

13. Date of hearing/place 22.03.2021 at Noida – online hearing


• For the Complainant Mr. Davender Singhal, Self

• For the insurer Mr. Mantosh Kumar & Dr. Madhukar Pandey



17) Brief Facts of the Case: This complaint is filed by Mr. Davender Singhal against M/s Star Health & Allied Insurance Co. Ltd. against repudiation of his hospitalization claim.


a) Complainant’s argument: The complainant and his family members were covered under Family Health Optima Insurance Plan bearing certificate no. P/161212/01/2019/017053, issued for the period from 07.02.2019 to 06.02.2020. The complainant was an advisor of Star Health Insurance Company and also covered under the same policy since the year 2016. The complainant was hospitalized in Lokpriya Hospital, Meerut, from 18.09.2019 to 20.09.2019 due to severe lower back pain and headache. The hospital raised bill for Rs. 10,800/- but the insurance company denied the claim for some discrepancy in the bill. He approached the hospital and was informed that the hospital had made two copies of the bills for internal adjustment of consultation charges to be given to the visiting doctors. In both the bills, the amount was same as Rs. 10,800/- but they made charges internally for Physician consultation fee, hospital management expenses and discount allowed to him (Ortho 1200 + hospital management 1400 = 2600 (-) discount 600=Rs. 2000). The complainant requested this office to intervene in the matter. b) Insurers’ argument: The insurance company submitted their SCN dated 25.02.2021 wherein they stated that the complainant had ported his policy in the year 2016 with them. He raised the claim in the 6th year of the policy. As per claim form, the complainant claimed an amount of Rs. 10,800/- for reimbursement of medical expenses. The Insured submitted the latest claim documents along with the claim form on 01/02/2020. He was admitted on 18-09-2019 at Lokpriya Hospital, Meerut and was discharged on 20-09-2019. As per Discharge Summary from

the treating hospital, the complainant was diagnosed with PIVD (Prolapsed, herniated or extruded intervertebral disc). On scrutiny of the claim documents, it was observed that the complainant was seeking reimbursement of hospitalization expenses for treatment of prolapsed intervertebral disc. The final bill of the above hospital available with the insurance company was different from that of the final bill submitted by the insured viz. professional charges were adjusted in the bill with hospital management charges. Thus, there was discrepancy in material facts in the medical records which amounted to misrepresentation. As per Condition No.6 of the policy if there was any misrepresentation of material facts the insurance company was not liable to make any payment in respect of any claim. Hence, the claim was repudiated and communicated to the treating hospital as well as the complainant vide letter dated 22-02-2020. As per the contract of Insurance, the Insured was expected to declare in the proposal about the details of his ailments/ sickness – past medical history and the reply for the same helps the insurer to evaluate the material facts and to decide whether to accept the proposal or not. 19) Reason for Registration of Complaint: - Repudiation of claim. 20) The following documents were placed for perusal.

a) Complaint letter

b) Discharge Summary

c) Policy document

d) SCN

21) Observations and Conclusion: - The complainant and the representatives of the insurance company were present for online hearing on 22.03.021. The complainant stated that the insurance company was raising objection in hospital bill. The insurance company reiterated that there was difference in the final bill of the hospital available with them and in the final bill submitted by the insured. Professional charges were adjusted in the bill with hospital management charges. They rejected the claim on the basis of discrepancy in material facts in the claim documents. During the hearing, the complainant was directed to submit a certificate from the hospital to certify the bill charged in different heads within a period of 2 days from the date of hearing. The complainant failed to submit the same even after a span of 8 days from the date of hearing.

Ongoing through the documents exhibited and the oral submissions made by both the parties during the hearing, it is observed that the hospital bill dated 20.9.2019 provided by the insurance company shows Room charges Rs. 6400/- and RMO charges Rs. 1000/-, Doctor charges Rs. 3400/-, net bill amount Rs. 10,800/- whereas the bill submitted by the complainant shows : Room Rent 6400/-, RMO charges 500/-, Orthopaedic surgeon 1200/-, Hospital Management Rs. 1400/-, Doctor charges Rs. 1400/-. This bill is unsigned. Further, the complainant again produced a copy of the same bill with handwritten corrections, with hospital stamp and sign. The complainant has failed to produce a valid and authentic bill from the hospital before this Forum. In view of the circumstances, the insurance company’s decision to repudiate the claim as per Condition No. 6 of the policy, that the claim is in any manner fraudulent or supported by any fraudulent means or device, misrepresentation whether by the Insured Person or by any other person acting on his behalf, seems to be justified. I see no reason to interfere with the decision of the insurance company to repudiate the claim.


AWARD

Taking into account the facts and circumstances of the case and the submissions

made by both the parties, I see no reason to interfere with the decision of the

insurance company to repudiate the claim.



PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATES OF A.P., TELANGANA & YANAM

(Under Rule 16(1)/17 of The Insurance Ombudsman Rules, 2017)

Ombudsman - Shri I. Suresh Babu

Case between: SRI CHILLA VENKATESWARA RAO………………The Complainant

Vs

M/s The United India Insurance Co. Ltd…………The Respondent

Complaint Ref. No. I.O.(HYD).H .051.2021.0348

Award No.: I.O.(HYD)/A/HI/ 0156 /2020-21

1. Name & address of the complainant

Mr. Chilla Venkateswara Rao

8-8-150, Flat #401, Laxmi Residency,

Girmajipet Masoom Ali Lane Near BATC

Muralikrishna Clinic,Warangal

Telengana state- 506 002

(Cell No. 94405-82707)

2. Policy No./Collection No. Type of Policy Duration of Policy/Policy period

500100/28/19/P1/11085970

Group medical insurance policy

1 year from 01/10/2019 to 30/09/2020

3. Name of the insured Name of the Policyholder

Mr. C .Venkateswara Rao

M/s Andhra Bank, account holder

4. Name of the insurer M/s The United India Insurance Company

Limited

5. Date of Repudiation -----

6. Reason for repudiation Claim settled after disallowing items not

payable

7. Date of receipt of the Complaint

17.02.2021

8. Nature of complaint Claim pertaining to medical insurance


10. Date of Partial Settlement Not mentioned 11. Amount of Relief sought Rs. 59,199/-

12. Complaint registered under Rule No.13.1 (b) of Ins. Ombudsman Rules, 2017

Rule 13.1 (b) – any partial or total repudiation of claims by the Life insurer, General Insurer or the Health insurer

13. Date of hearing/place 01.03.2021, online, Hyderabad


a) For the complainant Self

b) For the insurer Ms.Srijani

15. Complaint how disposed

Allowed

16. Date of Order/Award 01.03.2021


The complainant by virtue of being a customer of Andhra Bank was covered along with his

family under the Group medical insurance policy that was issued in the name of M/s Andhra

Bank by the respondent company. During the policy period of insurance, he had incurred a

hospitalization cost for which a claim made by him was sanctioned only for a short amount by

respondent. Unhappy with the short payment of his claim, he had represented his matter to

the Grievance department of respondent but to no avail. Hence, he had approached this Forum

with a hope to receive the balance amount claimed by him from the respondent.

18) Cause of Complaint: Short settlement of claim made against the group medical Insurance

policy.

a) Complainant’s argument: The complainant had lodged the complaint online. He had not given any reason as to why he should receive the balance amount claimed by him from the respondent. b) Insurer’s argument: No self contained note was submitted by the respondent. However, the letter issued by the Respondent on 03.02.2021 mentioned that they had paid the claim for Rs.141695/- on 18/12/2020. RS.59199/- was deducted towards PPE kits and IRDAI disallowed items as per the terms and conditions of the Policy. They informed over mail dated 26.12.2021 that they had further processed it and uploaded for payment of Rs.15,859/-to the insured.

19) Reason for Registration of Complaint: The insurer rejected the claim preferred by the complainant. As the complaint falls under Rule 13.1(b) of Insurance Ombudsman Rules, 2017, it was registered.

20) The following copies of documents were placed for perusal: a. Policy copy b. Discharge summary c. Correspondence with insurer d. TPA settlement note 21) Result of the personal hearing with both the parties: Pursuant to the notices given by this Forum both parties attended the online hearing at Hyderabad on 01.03.2021. The complainant stated he was admitted after being detected with Covid 19 positive to Yashoda hospital on 30.08.2020 and got discharged on 05.09.2020. His claim was short settled by Rs.59,199/- . Among the disallowed items the major amount pertained towards cost of PPE kits. He had obtained letter dated 11.09.2020 from the hospital informing that as control measures Rs.42000/- was charged for infection control consumables towards personal protective equipment (PPE Kits) at Rs.1500/- per kit at an average of 4 Kits per day used by consultant, DMO, Registrars, Dieticians, PRE nursing staff (3 shifts), ward boys, ayamma (3 shifts) etc for 28 days. The Respondent insurer informed of having paid Rs.1,41,695/- on 18/12/2020. Out of disallowed amount of Rs.59,199/- they had reprocessed and paid Rs.15859/- on 01/03/2021 through NEFT. They further informed that for the current year, Andhra Bank, Account holders group policy was renewed with National Insurance company and no longer with United India Insurance company. The complainant informed that till 30/09/2020 the policy was with united India insurance company and his admission in August 2020 was within the previous policy period.

The Forum observed that the items disallowed are N95 Mask virus protection kit, food & beverages, infection control charges, M R D Charges, Medical equipment details not available, Excess visit charges as per COVID package, Charges allowed as per GI guidelines in respect of cap, mask, swabs, face shield, vacationer. Further, profile charges for which details are not made available has not been considered, investigation reports not signed by pathologist are not allowed. General insurance council had issued a circular to all the GIPSA companies to pay the expenses incurred under different heads as per the amounts stipulated by them. This has been done so taking in to view the exorbitant amounts charged by hospitals from their patients towards COVID-19 treatment. However, in the instant case the insured has paid the entire amount to the hospital. In case the hospital has overcharged him being a network hospital, it was the respondent insurer who should have sorted out the matter with the hospital. The complainant cannot be made a scapegoat. Since reasonable rates are applicable to hospitals and not to the complainant, the Respondent Insurer is directed to accept and settle for Rs.43,340/- (Rs.59,199/- less Rs.15859/- already paid) subject to available sum insured under the policy.

A W A R D Taking into account the facts & circumstances of the case and the submissions made by both the parties during the course of the personal hearing and the information/documents placed on record, the insurer is directed to settle the claim for Rs.43340/-(Rs.59199/-less paid through NEFT Rs.15859/-) subject to available sum insured under the Policy.

The complaint is Allowed.

22) The attention of the Insurer is hereby invited to the following provisions of Insurance

Ombudsman Rules, 2017:

a) According to Rule 17(6), the insurer shall comply with the award within 30 days of the receipt of the award and intimate compliance to the same to the Ombudsman.

b) According to Rule 17(7), the complainant shall be entitled to such interest at a rate per annum as specified in the regulations, framed under the Insurance Regulatory & Development Authority of India Act from the date the claim ought to have been settled under the Regulations till the date of payment of the amount awarded by the Ombudsman.

c) According to Rule 17 (8), the award of Insurance Ombudsman shall be binding on the Insurers.

Dated at Hyderabad on the 1st day of March , 2021.

( I. SURESH BABU )

OMBUDSMAN

FOR THE STATES OF A.P.,

TELANGANA AND YANAM CITY

PROCEEDINGS BEFORE




Case between: SRI HARISH NARAYAN DANDOTIYA………………The Complainant

Vs

M/s The Oriental Insurance Co. Ltd…………The Respondent



1. Name & address of the complainant Mr. Harish Narayan Dandotiya

Godavari apartment, Block- C, Flat #409,

1-11-125, Shyamlal building, Begumpet,

Hyderabad,

Telengana State - 500 016

(Cell No. 82979-55051)


431801/48/2021/1097

PNB-Oriental mediclaim policy-2017- group

health

17.06.2020 to 16.06.2021


Mrs. Asha Dandotiya

Mr. Harish Narayan Dandotiya

4. Name of the insurer M/s The Oriental Insurance Co. Ltd.


6. Reason for repudiation Claim settled as per the GIPSA PPN package


8. Nature of complaint Claim pertaining to medical insurance policy

9. Amount of Claim Rs.104,750/-

10. Date of Partial Settlement 11.11.2020

11. Amount of Relief sought Rs. 69,710/-



13. Date of hearing/place 03.03.2021


a) For the complainant Mr.Harish Narayan Dandotiya

b) For the insurer Mr.P.Pradeep Kumar,Manager & Dr.Abbas




The complainant had insured his wife and himself under a group medical insurance policy

issued by respondent to the account holders of PNB. His wife was admitted to LV Prasad eye

institute, Hyderabad on 10.11.2020 to undergo a surgical procedure for her OD Descemets

Stripping Automated Eendothelial Keratoplasty (DSAEK). Since the respondent company had

settled only a partial sum of her hospitalization cost, the complainant had therefore

approached this Forum to seek justice.

18) Cause of Complaint: Partial payment of claim made against the medical Insurance policy.

a) Complainant’s argument: The complainant had stated that when his wife had undergone the same operation in the year 2015 where she had incurred a hospital expense of Rs. 78,450/-, the then TPA of respondent M/s Mediassist India had then settled her claim for an amount of Rs. 78,168/-. However, when she had incurred an amount of Rs. 104,750/- for the same treatment in the instant hospitalization, the current TPA M/s GHPL of the same respondent had allowed only an amount of Rs. 34,860/-. The reason given for disallowance of the remaining portion of claim was not agreeable to him because the PPN rates entered into between the insurer and hospital was never made known to their customer. Further, the declaration form which the hospital had insisted to sign prior to the commencement of treatment was complied

because one cannot expect that all the contents ought to be read at the time of such a stress. Moreover, it’s a general practice that such forms would mention all the facts were explained to their patient before obtaining the signature when in reality nobody would explain them to their patient. b) Insurer’s argument: The respondent has submitted the self contained note was submitted on 22.02.2021. They have stated that the earlier claim of Rs.78168/- was settled in 2015 as per the rates agreed by the hospital. The present claim was settled as per the GIPSA PPN rates came into effect from 28.08.2018 which were agreed by the L.V.Prasad Eye Institute. They have quoted the policy condition of Part A Expenses covered-Section ii Sub Section b-which states that “Any expense of reasonable and customary charges as defined under 3.42, or in excess of negotiated prices (in case of Network hospital) shall be borne by the insured”. They have also referred the policy condition of Section 3 : Procedure for availing Cashless Access Services in Network Hospital/Nursing Home para(d)-“Liability under the policy in respect of all expenses incurred in a Network Provider shall be subject to the pre-agreed rates between the Company/TPA and the Network Provider. This is irrespective of the claim being under cashless or re-imbursement”. The hospital had counseled the insured at the time of her admission regarding her eligible amount from her insurer. Whereas, in the instant case the insured had opted for a Deluxe package which was over and above the tariff for which she had agreed to bear the additional expense over and above the GIPSA –PPN rate as per the undertaking given which reads as follows:”On my own option, I wish to avail above facility and I hereby agree to pay on my free will, after being explained in detail by the hospital authority in my own and understandable language about the above mentioned facility/ procedure/ treatment and associated cost of it, which is over and above the agreed tariff for the treatment. Further, if I opt to go for final bill reimbursement which the insurance company, respective insurance company will reimburse only as per agreed tariff for the treatment and the balance amount will be borne by me/ patient

only”. Hence, the claim of the insured was settled in accordance with the GIPSA-PPN package.

19) Reason for Registration of Complaint: The insurer rejected the claim preferred by the complainant. As the complaint falls under Rule 13.1(b) of Insurance Ombudsman Rules, 2017, it was registered. 20) The following copies of documents were placed for perusal: a. Policy copy b. Discharge summary c. Correspondence with insurer d. Complaint copy & Form VI-A e. SCN 21) Result of the personal hearing with both the parties: Pursuant to the notices given by this Forum both parties attended the OnLine hearing at Hyderabad on 03.03.2021. The complainant stated that his wife who was validly covered under the mediclaim policy, got admitted in L V Prasad Eye Institute for the eye surgery of DSAEC under deluxe procedure and incurred an amount of Rs.104000/-. Prior intimation was given to the TPA about the admission and the estimated cost for the surgery. After the operation he has lodged the claim for reimbursement of the medical expenses incurred for the treatment. However his claim was settled for Rs.34860/- only quoting on the PPN rates which he is not aware of. Since the policy was insured for Rs.500000/- and continuously in force from 2012 he is eligible for the full reimbursement and requested for the full reimbursement of the claim. The Representatives of the respondent insurer stated that the claim was settled as per the policy terms and conditions. The hospital where the insured person got treatment is a network hospital and as per the policy condition all the expenses incurred in the network hospital is subject to the pre-agreed rates between the company and the network provider. The network provider has explained the insured person about her eligibility under the GIPSA package but preferred higher package knowing well that the balance has to be borne by them. They

reiterated that the claim was settled as per the GIPSA PPN rates which came into force from 28.08.2018 and as per the policy terms and conditions. Hence the settlement of claim is in order. Having heard the arguments from both parties and perusing documents made available to this forum, it has been observed that the dispute is on the application of PPN Rates for settlement of the claim. The complainant is relying on the previous claim settlement wherein he has got total claimed amount for the same of type of treatment whereas in the present case his claim was reduced drastically in spite of adequate insurance coverage. The respondent has justified their settlement of claim quoting the policy terms and conditions. The Forum is aware of the GIPSA PPN network agreements with the network hospitals and the pre-agreed rates for the listed procedures. The policy issued to the complainant has specifically mentioned the procedures applicable for claim settlement in the CONDITIONS No.5 of the policy. The policy condition No.5.2.iii(d) specifically states that the liability under the policy in respect of all expenses incurred in a network provider shall be subject to the pre-agreed rates between the company/TPA and the Network Provider and applicable for both cashless and re-imbursement claims. The forum has also observed that the representative of the network hospital has explained the complainant/patient on the GIPSA package rates for the procedure of DSAEK for which she was admitted and their eligibility under the policy. However the complainant has opted for higher package after submitting the undertaking to bear the additional expenses over and above the GIPSA PPN rates. In view of the above, the forum felt that the complainant is aware of the package rates and signed the undertaking on his own free will. It is also to be noted that the policy is the evidence of contract and subject to the terms and conditions of the policy. In view of the above observations the Forum felt that the settlement of the claim by the respondent is in agreement with the policy terms and conditions of the policy. In this connection we refer the case of M/s. Oriental Insurance Co. Ltd. vs. Sony Cheriyan on 19th August,1999 wherein the Hon’ble Supreme Court held that: “The Insurance policy between the insurer and the insured represents a contract between the parties. Since the insurer undertakes to

compensate the loss suffered by the insured on account of risks covered by the insurance policy, the terms of the agreement have to be strictly construed to determine the extent of liability of the insurer. The insured cannot claim anything more than what is covered by the insurance policy.” Considering the facts of the case, this Forum finds that the claim settlement of the Respondent Insurer in order and does not require any interference of this forum. Accordingly the complainant is disallowed.

A W A R D Taking into account the facts & circumstances of the case and the submissions made by both the parties during the course of the personal hearing and the information/documents placed on record, the settlement of the claim by the Respondent Insurer is found to be in order and in consonance with the terms and conditions of the policy and does not require any interference of this forum. The complaint is DISALLOWED. 22) The attention of the Insurer is hereby invited to the following provisions of Insurance


d) According to Rule 17(6), the insurer shall comply with the award within 30 days of the receipt of the award and intimate compliance to the same to the Ombudsman.

e) According to Rule 17(7), the complainant shall be entitled to such interest at a rate per annum as specified in the regulations, framed under the Insurance Regulatory & Development Authority of India Act from the date the claim ought to have been settled under the Regulations till the date of payment of the amount awarded by the Ombudsman.

f) According to Rule 17 (8), the award of Insurance Ombudsman shall be binding on the Insurers.

Dated at Hyderabad on the 5th day of MARCH, 2021.

( I. SURESH BABU )

OMBUDSMAN



PROCEEDINGS BEFORE




Case between: SRI VIKAS PENUMAKA………………The Complainant

Vs

M/s The National Insurance Co. Ltd…………The Respondent




Mr.Vikas Penumaka

H.No. 1-2-236/54A/B, Road #9, SRL Colony,

Mohan Nagar, Kothapet,

Hyderabad, Telengana state- 500 035

(Cell No. 80080-09877)


604200501810000809

Group mediclaim-Tailormade Insurance

24.09.2018 to 23.09.2019


A/c Mr. P. Vikas

M/s Virtusa Consulting Services Pvt. Ltd.

4. Name of the insurer M/s The National insurance Co. Ltd.


6. Reason for repudiation Standalone treatment not payable


12.02.2021


policy


10. Date of Partial Settlement ----

11. Amount of Relief sought Rs. 1,05,000/-



13. Date of hearing/place 08.03.2021, online Hyderabad


a) For the complainant Self b) For the insurer Mr.T.Bindu Madhav, AM

Mr.S.Ram Shankar, AO


Allowed



The complainant by virtue of being associated with M/s Virtusa Consulting services Pvt. Ltd. was

covered by them under the tailor made group medical insurance policy procured from the

respondent company. He was admitted to Nizam’s institute of Medical Sciences, Hyderabad to

undergo treatment for his IBD- Crohn’s disease on 13.09.2019. Since his claim towards the

hospitalization expense was not reimbursed by the respondent company, he had therefore

approached this forum to seek justice.

18) Cause of Complaint: Repudiation of claim against the medical Insurance policy.

a) Complainant’s argument: The complainant had stated that he was diagnosed initially with Crohn’s disease in Feb’19 and the disease being chronic in nature had no cure till date. He had to be managed with the administration of monoclonal antibody therapy- injection Infliximab- given to him every 4-8 weeks and whose cost was very high which involved him an amount of Rs. 7 Lakhs- Rs.9 Lakhs per annum. He had also brought the IRDAI circular released in Sep’19 to the notice of this forum to state that this therapy must be covered by insurers irrespective of the treatment being listed under daycare procedure/ in- hospital/ domiciliary hospital. He had pointed out that the respondent company had settled his claim which pertained to his initial admission in hospital during Sep ’19 whereas, the current treatment which was a part of the original admission but administered to him 4 weeks after the original admission, was denied by them. Further, he had stated that he had renewed his insurance policy in the month of Nov’19 and the sum insured was refreshed to the old amount of Rs. 2 Lakhs. Hence, he had justified his complaint. b) Insurer’s argument: Self contained note was submitted by the respondent over mail on 02.03.2021.They had issued a group tailor made policy to employer of the complainant M/s Virtusa Consulting services Pvt Ltd. The

complainant was admitted and diagnosed for Irrepressible Bowel Syndrome on 13.09.2019 and his claim was settled for Rs.84057/- on 30.09.2019. Subsequently they received a second claim under the policy for Rs.105000/- for treatment taken on 1/11/2019, wherein he was administered Infliximab injection. His claim was rejected since his admission in hospital was for a standalone treatment of 3rd dose of injection infliximab which falls under the category of monoclonal antibodies, and came under the standard exclusion of policy. Moreover IRDAI circular was effective from 1.10.2021 and apex body directed that modern treatments were subject to Policy issued, design and sub limits imposed. As per condition 3.12 “ Procedures/ treatments usually done in outpatient department(OPD) are not payable under the Policy even if converted to day care surgery procedure or as inpatient in hospital for more than 24 hours”. As per exclusion 3.13 Monoclonal antibody injection was not covered when administered standalone. There was no 24 hours hospitalization and no active line of treatment hence claim denied.

19) Reason for Registration of Complaint: The insurer rejected the claim preferred by the complainant. As the complaint falls under Rule 13.1(b) of Insurance Ombudsman Rules, 2017, it was registered. 20) The following copies of documents were placed for perusal: a. Policy copy b. Discharge summary c. Rejection letter d. Correspondence with insurer e. Self contained note with enclosures. 21) Result of the personal hearing with both the parties: Pursuant to the notices given by this Forum both parties attended the online hearing at Hyderabad on 08.03.2021. The complainant stated he got admitted to Nizam Institute of Medical sciences in Sept 2019 wherein he was administered Monoclonal

antibody injection toward Chron’s disease and IBD Inflammatory Bowel Disease and he underwent operation in July2016 towards Jegunal Resection. Initially he was given 3 cycles of the injection under Induction treatment and under the maintenance treatment he was asked to undergo once in every 8 weeks for life. His first claim was paid by the insurer while his second claim towards the cost of injection was denied. The respondent insurer informed that cost towards his treatment taken whist admitted in hospital was paid by them. Subsequent cost towards injection Infliximab taken as a standalone was not payable under the policy. There was no active line of treatment involved. IRDAI circular was effective after 01.10.2021 and that policy issued by them were prior to that date. When the insured was questioned on the procedure for administering the injection, it was informed that he was first given Hydrocortisone steroid injection followed by Infliximab dose given through IV in 500ml Saline and it took 8 hours. He also informed of being given a bed in the inpatient ward. The Forum observed that complainant was admitted on 13/09/2019 to 14/09/2019 . The Discharge summary showed he underwent surgery in 2016 and he had IBD Inflammatory Bowel disease Crohns (small bowel). As part of treatment he was asked to take among other oral medication 3 cycles of Remicade injection. His Ist dose of Remicade injection was given on 14/09/2019 in the hospital, he was asked to undergo 2nd dose on 29/09/2019 and a third dose on 28/10/2019 post discharge. The policy issued by the respondent insurer commenced from 24.09.2018 to 23.09.2019 and therefore he claimed for the 2nd dose of injection falling within the policy period. In the instant case the complainant a 28 years old got admitted with pain in abdomen post his operation in 2016. He was detected with IBD, given medication, asked to continue the injection infliximab as part of treatment. The injection cannot be taken in OPD because it has to be taken intravenous under the supervision of a specialist. Further, it was noticed from the Discharge Summary of the Hospital that the patient was advised to continue with the injection Infliximab monoclonal antibody and the same was

administered on various dates as per the cycles with prescribed duration. This process is called “Maintenance” in medical terminology. This Mainteance i.e., administration of the injections at regular intervals is as important as the administration of the injection at the time of treatment at the time of hospitalization. Thus maintenance is clearly part of the active line of treatment and it is part of the prescribed medications given to IBD patients. Hence, treating “Maintenance” as Standalone treatment which could be on OPD basis or not a part of Active line of treatment is not acceptable .Infliximab monoclonal antibody was not excluded under the policy since adjuvant chemotherapy was also covered under the same group policy. Hence, the forum directs the respondent insurer to admit and settle the claim treating the cost of injection as forming part of the hospitalization treatment subject to available sum insured under the policy.

A W A R D Taking into account the facts & circumstances of the case and the submissions made by both the parties during the course of the personal hearing and the information/documents placed on record, the insurer is directed to settle the claim towards cost of Infliximab injection subject to available sum insured under the policy. The complaint is Allowed. 22) The attention of the Insurer is hereby invited to the following provisions of Insurance


g) According to Rule 17(6), the insurer shall comply with the award within 30 days of the receipt of the award and intimate compliance to the same to the Ombudsman.

h) According to Rule 17(7), the complainant shall be entitled to such interest at a rate per annum as specified in the regulations, framed under the Insurance Regulatory & Development Authority of India Act from the date the claim ought to have been settled under the Regulations till the date of payment of the amount awarded by the Ombudsman.

i) According to Rule 17 (8), the award of Insurance Ombudsman shall be binding on the Insurers.

Dated at Hyderabad on the 8th day of March , 2021.

( I. SURESH BABU )

OMBUDSMAN



PROCEEDINGS BEFORE




Case between: SRI VIKAS PENUMAKA………………The Complainant

Vs

M/s The New India Assurance Co. Ltd…………The Respondent




Mr.Vikas Penumaka

H.No. 1-2-236/54A/B, Road #9, SRL Colony,

Mohan Nagar, Kothapet,

Hyderabad Telengana state- 500 035

(Cell No. 80080-09877)


71250034190400000020

Group mediclaim-Tailormade Insurance

1 year


A/c Mr P Vikas

M/s Virtusa Consulting Services Pvt. Ltd.

4. Name of the insurer M/s The New India Assurance Co. Ltd.


6. Reason for repudiation Standalone treatment not payable


12.02.2021


policy








a) For the complainant Self b) For the insurer Mr.Shyam


Allowed



The complainant was covered under a group medical insurance policy procured from the

respondent company. He was admitted to Nizam’s institute of Medical Sciences, Hyderabad on

26.06.2020 to undergo treatment for his IBD- Crohn’s disease. Since his 3 claims towards the

hospitalization expense were not reimbursed by the respondent company, he had therefore

approached this forum to seek justice.

18) Cause of Complaint: Repudiation of claims made against the medical Insurance policy.

a) Complainant’s argument: The complainant had stated that he was diagnosed initially with Crohn’s disease in Feb’19 and the disease being chronic in nature had no cure till date. He had to be managed with the administration of monoclonal antibody therapy- injection Infliximab- given to him every 4-8 weeks and whose cost was very high which involved him an amount of Rs. 7 Lakhs- Rs.9 Lakhs per annum. He had also brought the IRDAI circular released in Sep’19 to the notice of this forum to state that this therapy must be covered by insurers irrespective of the treatment being listed under daycare procedure/ in- hospital/ domiciliary hospital. He had pointed out that the other insurer M/s The National insurance Co. Ltd. had settled his original hospitalization claim which pertained to his initial admission in hospital during Sep ’19 whereas; the respondent company however had failed to honor his claim when this was a part of the original admission which was being administered to him every 4-8 weeks. Moreover, other insurers were honoring claims related to stand alone treatments of their customers. b) Insurer’s argument:

Self contained note was submitted by the respondent over mail. They had issued a New India Flexi Floater Group Mediclaim policy to credit card holders of Citi bank. The complainant was covered under the policy for a sum insured of Rs.8 Lakhs. The insured was treated at Nizam’s Institute of Medical sciences 3 times towards administration of Infliximab/ Remicade for Crohn’s Diesease amounting to Rs.313644/-. The claim was repudiated medically for administration of the Injection Infliximab required only a short stay a few hours and therefore 24 hours hospitalization was not warranted. As per 3.14.1 there was no minimum 24 hrs period of hospitalization. Also procedures/treatments usually done in outpatient department are not payable under policy even if converted as an in-patient in the hospital for more than 24 hours. Also administration of injection infliximab was not available in their listed day care procedures.

19) Reason for Registration of Complaint: The insurer rejected the claim preferred by the complainant. As the complaint falls under Rule 13.1(b) of Insurance Ombudsman Rules, 2017, it was registered. 20) The following copies of documents were placed for perusal: a. Policy copy b. Discharge summary c. Rejection letter d. Correspondence with insurer e. Self contained note with enclosures. 21) Result of the personal hearing with both the parties: Pursuant to the notices given by this Forum both parties attended the online hearing at Hyderabad on 08.03.2021. The complainant stated he was admitted to Nizam Institute of Medical sciences in Sept 2019 wherein he was administered Monoclonal

antibody injection toward Chron’s disease and IBD Inflammatory Bowel Disease and he underwent operation in July2016 towards Jegunal Resection. Initially he was given 3 cycles of the injection under Induction treatment and under the maintenance treatment he was asked to undergo once in every 8 weeks for life. His first claim was paid by the M/s National Insurance Company. The respondent insurer informed that there was no hospitalization for 24 hours, administering of the injection did not find place in their listed Daycare procedure. Therefore cost of injections Infliximab taken as a standalone was not payable under the policy. IRDAI circular was effective after 01.10.2021 and that policy issued by them were prior to that date. After renewal of the said policy, extra premium would be charged subject to further ceiling /capping for Monoclonal antibody injections they reiterated. When the insured was questioned on the procedure for administering the injection, it was informed that he was first given Hydrocortisone steroid injection followed by Infliximab injection through Intravenous in 500ml Saline and it took 8 hours. He also informed of being given a bed in the inpatient ward. The Forum observed that the complainant was admitted twice in Nizam’s Institute of Medical Sciences from 13/09/2019 to 14/09/2019 and again from 01/11/2019 to 02/11/2019. He had taken several cycles of injection on 20/02/2020,26/02/2020 and 01/11/2020 and each injection costed him around Rs.1,05,124/- . He was insured under two policies, with National Insurance Company who paid his expenses for hospitalization including cost of injection Infliximab. On exhaustion of the sum insured for the balance maintenance cycles once in 8 weeks he had claimed with the respondent insurer .The Discharge summary showed he underwent surgery in 2016 and he had IBD Inflammatory Bowel disease Crohns (small bowel). As part of treatment he was asked to take among other oral medication injections Infliximab/ Remicade which is a TNF (tumor necrosis factor) blocker. It is used to treat moderate to severe Crohn's disease. The policy issued by the

respondent insurer commenced from 01/07/2020 to 30/06/2021 and therefore he had claimed for the maintenance cycles under the policy. In the instant case the complainant a 28 years old got admitted with pain in abdomen post his operation in 2016. He was detected with IBD, given medication, asked to continue the injection infliximab as part of treatment. Since the above treatment was part of the main treatment given in the hospital, the Forum does not agree that it was a standalone treatment. The injection cannot be taken in OPD because it has to be taken intravenous under the supervision of a specialist and took around 8 hours each time. Further, it was noticed from the Discharge Summary of the Hospital that the patient was advised to continue with the injection Infliximab monoclonal antibody and the same was administered on various dates as per the cycles with prescribed duration. This process is called “Maintenance” in medical terminology. This Mainteance i.e., administration of the injections at regular intervals is as important as the administration of the injection at the time of treatment at the time of hospitalization. Thus maintenance is clearly part of the active line of treatment and it is part of the prescribed medications given to IBD patients. Hence, treating “Maintenance” as Standalone treatment which could be on OPD basis or not a part of Active line of treatment is not acceptable. Moreover monoclonal antibody treatment was not excluded under the policy as well as not included in the Listed Day care procedures. Since the treatment was part of the hospitalization for IBD, and the insured was paid by the First insurance company, it should be treated as part of the main treatment of Crohn’s Disease IBD. The GMC policy Terms of coverage 32.Corporate floater applicable for all ailments and corporate buffer limits show that the policy has wider coverage as well. Hence, the forum directs the respondent insurer to admit and settle the claims treating the cost of injection as forming part of the hospitalization treatment for IBD subject to available sum insured under the policy.

A W A R D Taking into account the facts & circumstances of the case and the submissions made by both the parties during the course of the personal hearing and the information/documents placed on record, the insurer is directed to settle the claim for Rs.3,13,644/- subject to available sum insured under the policy.

The complaint is Allowed.



j) According to Rule 17(6), the insurer shall comply with the award within 30 days of the receipt of the award and intimate compliance to the same to the Ombudsman.

k) According to Rule 17(7), the complainant shall be entitled to such interest at a rate per annum as specified in the regulations, framed under the Insurance Regulatory & Development Authority of India Act from the date the claim ought to have been settled under the Regulations till the date of payment of the amount awarded by the Ombudsman.

l) According to Rule 17 (8), the award of Insurance Ombudsman shall be binding on the Insurers.

Dated at Hyderabad on the 9th day of March , 2021.

( I. SURESH BABU )

OMBUDSMAN



PROCEEDINGS BEFORE




Case between: SRI UMA MAHESWARA RAO………………The Complainant

Vs

M/s BAJAJ ALLIANZ General Insurance Co. Ltd…………The Respondent




Mr. M Uma Maheswara Rao

5-10-93, Coolilane,

Kothagudem,Bhadradri District,Telangana.

PIN-507 101 (Cell No. 93464-65218)


OG-15-9999-9960-00000002/OG-18-1901-

6318-00000847

Travel prime holiday insurance policy- Group

05 days; 04/07/2017 to 08/07/2017


Mr Uma Maheswara Rao Maddukuri

M/s Shriram Financial Products Solutions

(Chennai) Pvt. Ltd.

4. Name of the insurer M/s Bajaj Allianz General Insurance

Company Ltd.


6. Reason for repudiation Complication arising from pre-existing

condition not payable


27.01.2021

8. Nature of complaint Claim pertaining to travel prime holiday

insurance policy








a) For the complainant Mr.M.Uma Mahashwara Rao

b) For the insurer Dr.Ravindra Shingate


DISMISSED

16. Date of Order/Award 17/03/2021


The respondent company had issued a 5 day Travel prime holiday insurance policy to the policy

holder to cover the risks mentioned in the policy to their employees who travel overseas. On

06.07.2017, the complainant being an insured person under the policy was admitted to

Bangkok Hospital, Pattaya where he was treated for acute myocardial infarction, Diabetes

Mellitus- type II, Dyslipidemia and was discharged on 09.07.2017. He had filed a claim with

respondent which was rejected by them. Aggrieved by the respondent’s decision to reject his

claim, he had therefore filed his complaint in this Forum to seek justice.

18) Cause of Complaint: Repudiation of claim made against the Travel Prime Holiday Insurance

policy.

a) Complainant’s argument: In his letter addressed to this Forum, the complainant had stated that he had travelled on 04.07.2017 to Thailand on a leisure trip. On the night of 05.07.2017, he developed chest pain and had therefore visited a hospital situated at Pattaya. The treating doctor had performed an angiography on him. He had rebutted the reason given by respondent who had rejected his claim by mentioning that he had developed sudden pain which according to him could not be endured if he had been suffering from it for quite a long time. He had no intention to take advantage of the policy of insurance to undergo treatment. Since it was a leisure trip undergone by him and which was planned well in advance with the insurance cover being provided to him also was for a period of 4 days only, the question of his trip overseas to undergo medical treatment did not therefore arise. He had also mentioned that he had shared all his pre-existing disease to respondent voluntarily and that he

had no malafide intention to cheat the insurer. He had borrowed money to pay his hospital bills and therefore he ought to receive his claim amount which he was rightfully entitled to. b) Insurer’s argument: The Respondent Insurer has submitted the self contain Note and confirmed issuance of the Travel Time Silver Policy to the group of 97 members which includes Mr. M. Uma Maheswara Rao from 04.07.2017 to 08.07.2017. During the policy period Mr.Uma Maheswara Rao had admitted in Pattaya Hospital and diagnosed as Myocardial infarction and underwent surgical intervention Procedure. After verifying the Discharge summary and Treatment records they have observed that the insured person had the history of Diabetes Mellitus and Dyslipedemia which existed prior to the inception of insurance policy. The current ailment for which he had undergone treatment being a complication that arose from his pre-existing medical condition, the policy of insurance did not therefore extend coverage as per section 2(14) which read:” the claim made for any medical condition or complication arising from it which existed before the commencement of the policy period, or for which care, treatment or advice was sought, recommended by or received from a physician is not payable”. The Insured had not disclosed his pre-existing diseases at the time of opting policy thus denying them to exclude from the policy. However the current ailment is related to his pre-existing diseases the claim is not falling under the scope, terms and conditions of policy and therefore it was repudiated trating it as the claim is inadmissible under the policy.

19) Reason for Registration of Complaint: The insurer rejected the claim preferred by the complainant. As the complaint falls under Rule 13.1(b) of Insurance Ombudsman Rules, 2017, it was registered. 20) The following copies of documents were placed for perusal: a. Policy copy b. Discharge summary c. Rejection letter d. Correspondence with insurer e. SCN

f. Medical Reports. 21) Result of the personal hearing with both the parties: Pursuant to the notices given by this Forum both parties attended the online hearing at Hyderabad on 01.03.2021. The complainant stated that he has visited Bangkak on Holiday trip along with a Group of 97 members and covered under Travel Prime Holiday Insurance Policy(Group) issued by M/s.Bajaj Allianz General Insurance Co.Ltd., from 04/07/2017 to 08/07/2017. During the holiday period he has developed acute chest pain and admitted in Bankok Pattaya Hospital on 6/7/2017. He had diagnosed as Acute Myocardial Infarction and under gone Coronary Angiography with PCI and stent at proximal LAD. He was discharged on 09/07/2017 and lodged claim for reimbursement of hospitalization expenses under the Holiday Insurance Policy. However his claim was rejected on the grounds of his pre-existing diseases. Aggrieved with the decision of the insurer he has approached this Forum for justice. The Respondent Insurer has justified their rejection of claim on the ground of the pre-existing conditions of the Insured. They have verified the previous medical history and came to know that the compliant has history of Diabetes Mellitus and Dyslipidemia (Abnormally elevated Cholesterol or fats in the blood) prior to the commencement of the policy and the current ailment is direct complication of these pre-existing diseases. As per the policy Exclusion 2.14 the Company shall have no liability to make payment in respect of any medical condition or complication arising from the diseases pre-existed prior to the commencement of the policy. Since the present ailment is related to the pre-existing conditions of the insured the repudiation of the claim is in order and in compliance of the policy terms and conditions. The Forum has heard the arguments from both sides and perused all the documents made available to us thoroughly. The complainant was covered under the Travel Prime Holiday Insurance Policy(Group) bearing No.OG-15-9999-9960-00000002/OG-18-1901-6318-00000847 for the period from 04/07/2017 to 08/07/2017 with worldwide coverage Excluding USA and Canada. The policy covers Medical expenses and Evacuation up to USD 50000 along with other benefits. While the insured is holidaying in Bangkok Pattaya he has got acute

chest pain and admitted in Bangkok Hospital, Pattaya on 6/7/2017. He was diagnosed as Myocardial infarction and underwent surgical intervention Procedure: PCI at LAD (Percutaneous Coronary Intervention at left anterior descending artery). As per the Discharge Summary the Final Diagnosis was stated as: (1)ACUTE MYOCARDIAL INFARCTION (2)DM Type II (3) Dyslipidemia. The Complainant was discharged on 09/07/2017 and lodged the claim for reimbursement of expenses after returning back to India. The Respondent has registered the claim and processed the claim basing on the documents submitted by the complainant. While processing the claim the Respondent Insurer has observed that the insured had pre-existing conditions of Diabetes Mellitus and Dislipedemia. They have also obtained the previous treatment details and observed that the insured was taking treatment for Cholesterol(athrosclerosis) and Daibetes Mellitus from Dr. C. Kavitha Rao prior to the policy commencement. However, the complainant insured has not declared the pre-existing ailments/ complications while obtaining the policy thus denying the R.I. an opportunity to evaluate the risk properly. Keeping in view of the aforementioned discussions the Forum has felt that the complainant had pre-existing complications prior to commencement of the policy and taking treatment from Dr.Kavitha Rao C for the said ailments. The Discharge Summary has also confirmed the existence of the DM TYPE II and DYSLIPIDEMIA in the Final Diagnosis which might have contributed for the present illness of Acute Myocardial Infarction. It is noted that as per the policy Exclusion 2(14) the Respondent Insurer shall not be liable to make payment in respect of “Any medical condition or complication arising from it which existed before the commencement of the policy period, or for which care, treatment or advice was sought, recommended by or received from a physician”. The Forum has noted that under the Important Notice of the Policy Certificate cum policy Schedule it was mentioned “The policy does not cover any Pre-Existing medical condition/Injury/illness/deformity and complications arising out from them that are declared or undeclared“. Keeping in view of the above, the Forum is of the opinion that the complainant-insured has pre-existing complications and the current ailment is related to the pre-existing conditions of the complainant. The Complainant-Insured is taking treatment for the pre-existing conditions and did not disclose the same to the insurer at the time of proposing

the insurance which will be construed as suppression of material facts. Since the claim falls under the Policy Exclusion No. 2(14) the rejection of claim by the Respondent Insurer is in congruent with the policy terms and conditions and concurs with the decision of the Respondent Insurer.

A W A R D Taking into account the facts & circumstances of the case and the submissions made by both the parties during the course of the OnLine hearing and the information/documents placed on record, the Forum upheld the repudiation of the claim by the Respondent Insurer. The complaint is DISALLOWED.

Dated at Hyderabad on the 17th day of 2021.

( I. SURESH BABU )

OMBUDSMAN



PROCEEDINGS BEFORE




Case between: SRI IRUKULLA VENKATA KOTESWAR RAO………………The Complainant

Vs





Mr. Irukulla Venkata Koteswar Rao- HGA

Life Insurance Corporation of India,

Khammam, TELANGANA- 507 002

(Cell No. 94403-54254)


12070034200400000007

New India Flexi Floater Group mediclaim

policy

01.04.2020 to 31.03.2021


M/s Life Insurance Corporation Of India

A/c of Mr I V Koteswara Rao


5. Date of Repudiation ----

6. Reason for repudiation Claim settled as per the room rent eligibility


05.02.2021

8. Nature of complaint Claim pertaining to Group mediclaim

insurance policy

9. Amount of Claim 285,253/-

10. Date of Partial Settlement Not mentioned

11. Amount of Relief sought 136,520/-





a) For the complainant Mr. I.V.Koteswara Rao

b) For the insurer Dr.P.Kranthi Rekha


Allowed



The complainant by virtue of being an employee of M/s LIC of India was covered under the

Group medical insurance policy obtained by his employer from the respondent company. He

and his wife were admitted to AIG Hospitals, Hyderabad on 30.08.2020 and 02.09.2020

respectively to undergo treatment for COVID-19 infection. Whereas, the respondent company

had paid the claim of his spouse completely after disallowing the discount offered by hospital,

his claim was considered at 50% of the total amount. Unhappy with the improper settlement of

claim by respondent, he had therefore approached this Forum to seek justice.

18) Cause of Complaint: Partial payment of claim made against the group medical Insurance

policy.

a) Complainant’s argument: In his letter addressed to this Forum, the complainant had stated that at the time of admission to hospital, his wife and he were allotted a single room for which the hospital had charged Rs. 10,000/- per day and Rs. 20,000/- per day respectively towards room charges. His wife’s hospitalization cost was Rs. 167,941/- out of which a discount of Rs. 16,686/- was offered to her. The claim was admitted by respondent for

an amount of Rs. 148,110/- as against her claim amount of Rs. 151,255/-. Whereas, in his case, the total hospitalization cost was Rs. 316,947/- out of which a discount of Rs. 31,694/- was given. The respondent had admitted his claim for Rs. 148,733/- which was short by Rs. 136,520/- from the total amount claimed by him. His plea was that only the room rent charged to him was double the room charges levied on his wife and the charges levied under other heads remained the same in respect of his and his wife’s hospital bills. The respondent however had disallowed more than 50% of the charges by giving a reason that the room rent was double the eligibility. Since their admission to hospital could take place only after repeated requests made to hospital and owing to pandemic both of them could not get rooms with lower charges, it was therefore inevitable for them to get admitted to rooms of higher tariffs. He had therefore requested this Forum that he should be reimbursed the actual amounts charged under other heads as considered in his wife’s case by respondent. b) Insurer’s argument: The Respondent Insurer has submitted the SCN and justified their claim settlement. As per the policy condition the complainant’s eligible room rent is Rs.10000/- whereas he has opted for higher room rent of Rs.20000/-. As per the policy condition when the insured had opted higher room rent the payment of all other expenses incurred at the hospital except medicines shall be proportionately reduced. They have stated that the claim was processed as per the policy terms and conditions and hence the settlement of claim is in order. 19) Reason for Registration of Complaint: The insurer partially settled the claim preferred by the complainant. As the complaint falls under Rule 13.1(b) of Insurance Ombudsman Rules, 2017, it was registered. 20) The following copies of documents were placed for perusal: a. Policy copy b. Discharge summary & Hospital Detailed Bill c. Correspondence with insurer d.SCN

21) Result of the personal hearing with both the parties: Pursuant to the notices given by this Forum both parties attended the OnLine hearing at Hyderabad on 23.02.2021. The complainant stated that his wife and himself were attacked with Covid-19 disease during the month of August,2020 and rushed to Hyderabad for getting treatment. Since the Covid-19 is at its peak at that time it was very difficult for them to get admittance in any hospital. They moved from pillar to post to get admission in a hospital and with great difficulty they could able to get admission in AIG hospital. They were forced to go for higher room rent because of the scarcity of rooms in the hospital. After discharging from the hospital they have lodged claims for reimbursement of hospital expenses. Out of the two claims lodged, his wife claim was settled in full and his claim was partially settled. The reasons for reduction of the claim amount was attributed to the higher room rent opted and the resultant application of proportionate clause of the policy. The complainant stated that they were forced to go for higher room category because of the emergency situation and requested to consider his claim without applying the proportionate clause. The respondent insurer has referred the policy terms and conditions of the Group insurance policy issued to M/s. LIC of India covering their employees and family members. As per the policy terms the payment of hospital expenses except medicines shall be reduced proportionately if the insured persons have opted higher room rent than their eligible amount. Keeping in view of the policy conditions one claim was paid in full and the other was settled after deducting the proportionate charges. Hence they confirmed the settlement of claims is in order. During the course of the online hearing the Respondent has stated that they have observed certain discrepancies in the apportionment of room rent which was not proportionately distributed between the occupants of the Room. Hence they have requested for some time to obtain clarifications from the Hospital on the disproportionate sharing of the room rent. The Forum has conceded their request and allowed time to obtain the proof in support of their new contentions. Even after a lapse of more than three weeks the Respondent insurer has failed to submit

the clarifications from the hospital. Since the Respondent has failed to submit any new evidence in spite of allowing sufficient time, the Forum has proceeded to finalize the complaint basing on the available information and documents. The Forum has observed that the claimants have faced tremendous pressure to get admission in a hospital for the treatment of the Covid-19 pandemic disease. All the hospitals and covid-care centers are flooded with Covid-19 patients and the situation is very alarming at that point of time. Covid-19 is a new disease which requires immediate treatment. They cannot delay or postpone the treatment. Hence the complainant has no choice except to accept the higher room category to save himself and his wife from the clutches of the covid-19 disease. Hence applying the proportionate clause to reduce the actual expenses incurred by the complainant is like punishing the victim twice. The Insurance Authority has appraised the situation and issued several Circulars and guidelines for the speedy and liberal settlement of Covid-19 claims. It is to be noted that the Covid-19 is a new disease with no established protocols and standardized treatment. Even though the Government of Telangana has issued guidelines fixing the rates for Covid-19 treatment the private health care providers never followed the same and continued to charge exorbitant rates from the unfortunate victims. Keeping in view of the above discussions, the Forum felt that application of the proportionate clause basing on the higher Room Rent for Covid-19 treatment is not justified. Hence the Forum directs the R.I. to reassess the claim without applying the proportionate clause and release the balance claim amount which was arrived at Rs.21,275/-. Rest of the claim assessment is order and no interference is required from this office.

AWARD Taking into account the facts & circumstances of the case and the submissions made by both the parties during the course of the personal hearing and the information/documents placed on record, the insurer is directed to release the balance claim amount of Rs.21,275/- The complaint is allowed.



m) According to Rule 17(6), the insurer shall comply with the award within 30 days of the receipt of the award and intimate compliance to the same to the Ombudsman.

n) According to Rule 17(7), the complainant shall be entitled to such interest at a rate per annum as specified in the regulations, framed under the Insurance Regulatory & Development Authority of India Act from the date the claim ought to have been settled under the Regulations till the date of payment of the amount awarded by the Ombudsman.

o) According to Rule 17 (8), the award of Insurance Ombudsman shall be binding on the Insurers.

Dated at Hyderabad on the22nd day of MARCH,2021.

( I. SURESH BABU )

OMBUDSMAN



PROCEEDINGS BEFORE




Case between: SRI ERUKULLA SAMBASIVA RAO………………The Complainant

Vs



Award No.: I.O.(HYD)/A/HI/ 0 174 /2020-21


Mr. Erukulla Sambasiva Rao- MPO

Life Insurance Corporation of India,

Khammam

TELANGANA- 507 002

(Cell No. 94403-54254)


12070034200400000007

New India Flexi Floater Group mediclaim

policy

01.04.2020 to 31.03.2021


M/s Life Insurance Corporation Of India

A/c of Mr. Erukulla Sambasiva Rao


5. Date of Repudiation ----

6. Reason for repudiation Claim settled as per the room rent eligibility


05.02.2021

8. Nature of complaint Claim pertaining to Group mediclaim

insurance policy

9. Amount of Claim 310,847/-

10. Date of Partial Settlement Not mentioned 11. Amount of Relief sought 169,046/-





a) For the complainant Mr.E.Sambasiva Rao

b) For the insurer Dr.Kranthi Rekha


Allowed



The complainant by virtue of being an employee of M/s LIC of India was covered along with his

family under the Group medical insurance policy obtained by his employer from the respondent

company. He, his wife, and his son were admitted to AIG Hospitals, Hyderabad on 31.08.2020

to undergo treatment for COVID-19 infection. Whereas, the respondent company had paid the

claim of his spouse completely after disallowing the discount offered by hospital, his claim was

considered at 50% of the total amount. Unhappy with the improper settlement of claim by

respondent, he had therefore approached this Forum to seek justice.

18) Cause of Complaint: Partial payment of claim made against the group medical Insurance

policy.

a) Complainant’s argument: In his letter addressed to this Forum, the complainant had stated that at the time of admission to hospital, his son and he were allotted single room for which the hospital had charged Rs. 20,000/- per day and in case of his wife Rs. 10,000/- per day respectively towards room charges. His wife’s hospitalization cost was Rs. 121066/- out of which a discount of Rs. 12,086/- was offered to her. The claim was admitted by respondent for and settled the claim fully for Rs.108,980/- without any deductions. . Whereas, in his case, the total hospitalization cost was Rs. 177,355/- out of which a discount of Rs. 17,735/- was given. The respondent had admitted his claim for Rs. 69,618/- which was short by Rs. 90,002/- from the total amount claimed by him. As regards his son, the total hospitalization cost was Rs. 167,994/- out of which a discount of Rs. 16,767/- was given by hospital. The claim of his son was admitted for Rs. 72,183/- which was short paid by Rs. 79,044/-. His plea was that only the room rent charged to him and his son was double the room

charges levied on his wife and the charges levied under other heads remained the same in respect of his, his son’s and his wife’s hospital bills. The respondent however had disallowed more than 50% of the charges by giving a reason that the room rent was double the eligibility. Since their admission to hospital could take place only after repeated requests made to hospital and owing to pandemic all of them could not get rooms with lower charges, it was therefore inevitable for them to get admitted to rooms of higher tariffs. He had therefore requested this Forum that he and his son should be reimbursed the actual amounts charged under other heads as considered in his wife’s case by respondent. b) Insurer’s argument: The Respondent Insurer had submitted their self contained note with the policy terms and conditions. They have stated that the insured and his family members are eligible for Rs.10,000/- Room Rent per day. In case of admission to a Room Rent at rates exceeding the said limits, the reimbursement of all other expenses incurred at the Hospital except the costs of medicines, drugs and implants shall be reduced proportionately. Since the insured and his son has opted for higher Room Rent the expenses were reduced proportionately. Hence they have justified their settlement of claims which are in consonance with the terms and conditions of the policy.

19) Reason for Registration of Complaint: The insurer rejected the claim preferred by the complainant. As the complaint falls under Rule 13.1(b) of Insurance Ombudsman Rules, 2017, it was registered. 20) The following copies of documents were placed for perusal: a. Policy copy b. Discharge summary c. Correspondence with insurer d.SCN 21) Result of the personal hearing with both the parties: Pursuant to the notices given by this Forum both parties attended the online hearing at Hyderabad on 23.02.2021. The complainant stated

that his wife, son and himself were attacked with Covid-19 disease during the month of August,2020 and rushed to Hyderabad for getting treatment. Since the Covid-19 is at its peak at that time it was very difficult for them to get admission in a hospital. With great difficulty and after waiting for hours together they could able to get admission in AIG hospital. They were forced to go for higher room rent because of the scarcity of rooms in the hospital. After discharging from the hospital they have lodged claims for reimbursement of hospital expenses. Out of the three claims lodged, his wife claim was settled in full and the other two claims were partially settled. The reasons for reduction of the claim amount was attributed to the higher room rent opted and application of proportionate clause of the policy. The complainant stated that they were forced to go for higher room category because of the prevailing pandemic situation and requested to consider their claims without applying the proportionate clause on the hospital expenses. The respondent insurer has referred the policy terms and conditions of the Group insurance policy issued to M/s. LIC of India covering their employees and family members. As per the policy terms certain expenses will be reduced proportionately if the insured persons have opted higher room rent than their eligible amount. Keeping in view of the policy conditions one claim was paid in full and deducted proportionate charges in the other two claims. Hence they have justified their settlement of claims basing on the policy terms and conditions. During the course of the online hearing the Respondent Insurer has stated that they have observed certain discrepancies in the apportionment of room rent. They have stated that even though the room was shared by two of his family members the rent was not shared proportionately. Hence they have requested for some time to obtain clarifications from the Hospital on the disproportionate sharing of the room rent. The Forum has conceded their request and allowed time to obtain the proof in support of their new contentions. However, even after a lapse of more than three weeks the Respondent insurer has failed to submit the evidence from the hospital.

Since the Respondent has failed to submit any new evidence in spite of allowing sufficient time, the Forum has proceeded to finalize the complaint basing on the available information and documents. The Forum has observed that the claimants have faced tremendous pressure to obtain admission in a hospital for getting treatment of the pandemic disease. All the hospitals and covid care centres are flooded with Covid-19 patients and the situation is very alarming at that point of time. Covid-19 is a new disease and the treatment cannot be postponed because of its pandemic nature. The complainant has not opted for the higher room rent on his own will. He was forced to accept the same to save him and his family members from the clutches of the pandemic. Hence applying the proportionate clause to reduce the actual expenses incurred is like punishing the victims twice. The Insurance Authority has understood the situation and issued several Circulars and guidelines for the speedy and liberal settlement of Covid-19 claims. It is observed that exorbitant rates are being charged by the private health care providers violating the guidelines issued by the State and Central Governments. The fact of not obtaining clarifications from their network hospital on the disproportionate apportionment of the room rent clearly shows the irregularities being perpetuated by the private network hospitals. Keeping in view of the aforementioned discussions, the Forum has felt that application of the proportionate clause basing on the room rent is not justified for Covid-19 treatment and direct the Respondent Insurer to revise the claim release the balance claim amount. Consequently the claim amounts were revised as follows: Claim ID Name of the

Claimant Amount Settled

Revised Amount

Amount Allowed

101320446 E. Sambasiva Rao

69618 93123 23505(19005+4500)

167996.0 E G K Hemanth

72183 93539 21356(17243+4113)

A W A R D Taking into account the facts & circumstances of the case and the submissions made by both the parties during the course of the online hearing and the information/documents placed on record, the insurer is directed to settle the claims without applying the proportionate clause and release the balance claim amounts. The complaint is Allowed. 22) The attention of the Insurer is hereby invited to the following provisions of Insurance


p) According to Rule 17(6), the insurer shall comply with the award within 30 days of the receipt of the award and intimate compliance to the same to the Ombudsman.

q) According to Rule 17(7), the complainant shall be entitled to such interest at a rate per annum as specified in the regulations, framed under the Insurance Regulatory & Development Authority of India Act from the date the claim ought to have been settled under the Regulations till the date of payment of the amount awarded by the Ombudsman.

r) According to Rule 17 (8), the award of Insurance Ombudsman shall be binding on the Insurers.

Dated at Hyderabad on the 22nd day of MARCH,2021.

( I. SURESH BABU )

OMBUDSMAN



PROCEEDINGS BEFORE




Case between: SRI T RAJESH………………The Complainant

Vs

M/s The United India Insurance Co. Ltd…………The Respondent




Mr. T Rajesh

#405, Oxford Enclave,

9-1-128 & 128/1, S D Road,

Secunderabad,Telengana state- 500 003

(Cell No. 98852-75947) (99631-93385)


500100/28/19P112/408520

Group policy- IBA Retirees

1 year


Mr. Thirumala Ravindranath

M/s State Bank of Hyderabad

4. Name of the insurer M/s The United India Insurance Co. Ltd.


6. Reason for repudiation Claim not payable beyond the GIPSA

Package which is paid already by the other

insurer.


03.03.2021


policy


10. Date of Partial Settlement 22.12.2020

11. Amount of Relief sought Rs. 400,000/- 12. Complaint registered

under Rule No.13.1 (b) of Ins. Ombudsman Rules, 2017




a) For the complainant Mr.T.Rajesh,S/o.T.Ravindranath

b) For the insurer Ms.Srijani Saha and Dr.Sneha Jadhav


ALLOWED



The complainant’s father was covered by his employer M/s State Bank of Hyderabad under the

group medical insurance policy taken by them from respondent for their retirees. On

10.10.2020, his father was admitted to M/s Apollo Hospitals, Secunderabad where he had

undergone PTCA + Stent to LAD on 15.10.2020 for his triple vessel disease. Out of the total

hospitalization expense of Rs. 814,476/- incurred by his father, the other insurance company

had settled his claim as per their maximum liability under their policy whereas, the respondent

insurer had failed to honor the remaining amount claimed by him against their insurance policy.

18) Cause of Complaint: Repudiation of claim made against the medical Insurance policy. a) Complainant’s argument: In his letter addressed to this Forum, the complainant had stated that the matter was communicated to the respondent after the claim of his father was repudiated by the respondent’s TPA M/s. Safeway Insurance TPA Pvt. Ltd. but since the respondent had failed to respond to the e-mail, he had therefore sought this Forum’s help to enable his father to receive the balance claim amount from the respondent. b) Insurer’s argument: In the Self contained note submitted to this Forum, the Respondent had stated that as per the PPN rates, the maximum liability payable under the policy is Rs.3,02,858/- for the treatment of PTCA and Coronary Angiography underwent by the complaint at Apollo Hospitals from 10/10/2020 to 21/10/2020. On scrutiny of the claim documents they have observed that the claim was already settled by Future General Insurance for Rs.400,000/-. As per the respondent’s liability, the maximum amount that was payable was Rs. 302,858/- as per the GIPSA package entered into with the hospital and since the amount paid by the other insurer was more than the GIPSA package payable by respondent, the claimant therefore was not entitled to any further sum. The claim was therefore recommended for repudiation as per the respondent’s policy terms and conditions. 19) Reason for Registration of Complaint: The insurer rejected the claim preferred by the complainant. As the complaint falls under Rule 13.1(b) of Insurance Ombudsman Rules, 2017, it was registered.

20) The following copies of documents were placed for perusal: a. Policy copy b. Discharge summary c. Rejection letter d. Correspondence with insurer e. SCN 21) Result of the personal hearing with both the parties: Pursuant to the notices given by this Forum both parties attended the online hearing at Hyderabad on 19/03/2021. The complainant stated that his Father was a retired employee of SBH and covered under two Group policies issued by M/s.Future Generali and M/s.United India Insurance Co.Ltd., for Rs.400000/- each. His father was admitted in Apollo Hospitals on 10/10/2020 due to heart attack and diagnosed with CAD, DM, HTN, PULMONARY EDEMA and underwent PTCA and Corona Angiography. The hospital has charged Rs.789434/- out of which the Future Generali has paid Rs.400000/- under cashless settlement and for the balance amount they have lodged claim with M/s. United India for reimbursement of expenses. However the insurer has rejected his claim stating that they have received more than the admissible claim amount which was worked at Rs.302858/- as per the PPN rates agreed by the hospital. Aggrieved with the decision of the insurer the complainant had approached the Forum for justice. The Respondent insurer has stated that the insured was treated in the net work hospital and the claims are subject to the compliance of the pre-agreed packaged pricing. As per the PPN agreement the total liability was arrived at Rs.302858/-for the surgical procedures done at the hospital. Since the claim was already settled by Future Generali for Rs.400,000/- which is more than their admissible amount, they were absolved from liability under the policy. Hence they have justified their rejection of the claim. Upon hearing the arguments from both sides and perusal of the documents made available to this Forum it has been observed that the Insured was covered under two group Mediclaim policies issued by M/s.Future Generali and M/s.United India for Rs.400000 each. Both

the policies are subsisting at the time of hospitalization. During the policy Period the insured person was admitted in the Apollo Hospitals with severe heart complications. He was on ventilator for two days and after stabilization of his condition, Coronary Angiogram was done and the principal diagnosis was arrived with(1)Acute Coronary Syndrome Myocardial Infarction(2)Acute Pulmonary Edema(3)Triple Vessel Disease(4)Hypertension(5)Type II Diabetes Mellitus. After complete evaluation the PTCA STENT was done twice on 15/10/2020 and 19/10/2020 and kept under post operative care. He was discharged on 21/10/2020 after of his condition was stabilized with post operative advice and charged Rs.789,434/- towards the services rendered during his stay in the hospital. Out of the Billed amount of Rs.789434 the Furture Genarali has paid Rs.400,000 under cashless settlement and the balance amount of Rs.389,434/- was paid by the insured. Since the Sum Insured under the first policy issued by the Future Generali was exhausted they have lodged the claim on the second policy issued by Respondent insurer for the reimbursement of the balance amount. The Respondent has arrived their liability under the policy at Rs.302858/- basing on the PPN agreement with the said hospital and rejected the claim lodged by the complaint stating that they have received more than the admissible claim amount from the other insurer. Since the Respondent Insurer has refused to accept their liability basing on the claim settled by the other insurer the Forum has referred the Health Regulations applicable for the multiple policies and reproduced for verification and application: IRDAI HEALTH REGULATIONS:: CHAPTER III: GENERAL PROVISIONS RELATING TO HEALTH INSURANCE: 24.ii. If two or more policies are taken by an insured during a period from one or more insurers to indemnify treatment costs, the policy holder shall have the right to require a settlement of his/her claim in terms of any of his/her policies. 1. In all such cases the insurer who has issued the chosen policy shall

be obliged to settle the claim as long as the claim is within the limits of and according to the terms of the chosen policy.

2. Balance claim or claims disallowed under the earlier chosen

policy/policies may be made from the other policy/policies even if the sum insured is not exhausted in the earlier chosen policy/policies. The insurer(s) in such cases shall independently settle the claim subject to terms and conditions of other policy/policies so chosen.

3. If the amount to be claimed exceeds the sum insured under a single

policy after considering the deductibles or co-pay, the policy holder shall have the right to choose insurers from whom he/she wants to claim the balance amount.

4. Where an insured has policies from more than one insurer to cover

the same risk on indemnity basis, the insured shall only be indemnified the hospitalization costs in accordance with the terms and conditions of the chosen policy.

Keeping In view of the Regulations applicable for Multiple policies, the Forum felt that the policy holder shall have the right to require a settlement of his claim in terms of his policy from one or more insurers to get indemnification of his hospital expenses. It is obligatory on the Insurers to settle the claim as long as the claim is within the limits of and according to the terms of the chosen policy. When the claim was lodged for the balance amount the insurer in such cases shall independently settle the claim subject to terms and conditions of their policy. Since the Regulations are clear and unambiguous on the settlement of claims when multiple policies are involved the Respondent could not avoid his responsibility in indemnifying the expenses incurred by the insured. Hence the forum felt that the complainant has every right to get reimbursement of the balance amount from the respondent who is liable to act independently and settle the claim in accordance with the terms and conditions of their policy. In view of the aforementioned discussions the Forum rejects the repudiation of the claim by the Respondent and directs the Respondent to settle the claim as per the terms and conditions of the policy. Since the Respondent has arrived their liability at Rs.302858/- basing on their policy terms and conditions as against the claimed amount of

Rs.389434/-, the Forum directs the R.I. to settle the claim for Rs.302858/-. Further the Respondent is directed to process the pre-hospitalization and post-hospitalization claims basing on the documents submitted by the complaint, since the main claim was admitted.

A W A R D Taking into account the facts & circumstances of the case and the submissions made by both the parties during the course of the personal hearing and the information/documents placed on record, the insurer is directed to settle the claim for Rs.302858. The complaint is ALLOWED. 22) The attention of the Insurer is hereby invited to the following provisions of Insurance


s) According to Rule 17(6), the insurer shall comply with the award within 30 days of the receipt of the award and intimate compliance to the same to the Ombudsman.

t) According to Rule 17(7), the complainant shall be entitled to such interest at a rate per annum as specified in the regulations, framed under the Insurance Regulatory & Development Authority of India Act from the date the claim ought to have been settled under the Regulations till the date of payment of the amount awarded by the Ombudsman.

u) According to Rule 17 (8), the award of Insurance Ombudsman shall be binding on the Insurers.

Dated at Hyderabad on the23rd day of March , 2021.

( I. SURESH BABU )

OMBUDSMAN




Mrs. Anjani Devi Annem

Flat#502, Moghal Marvel Apartments,

Street #18, Himayath Nagar,

Hyderabad,Telengana state- 500 029

(Cell No. 90008-66621)


120100/12586/2018/AO16898/209

Group Assurance Health plan- Individual

type

1 year; 16.07.2019 to 15.07.2020


Ms. Annem Anjani Devi

M/s Canara Bank

4. Name of the insurer M/s HDFC ERGO Health Insurance Co. Ltd.

5. Date of Repudiation -----

6. Reason for repudiation No reason given


26.02.2021


policy

9. Amount of Claim Rs. 7 Lakhs

10. Date of Partial Settlement 14.02.2020 for Rs. 5 Lakhs

11. Amount of Relief sought Rs. 1 Lakh plus Cumulative bonus





a) For the complainant Self, online, Hyderabad

b) For the insurer Mr.Sachin Kumar Varma


Allowed


The complainant, 37 years old, had purchased an annual medical insurance policy through the

intermediary M/s Canara Bank who had procured the same from respondent company. During

the second renewal period of her insurance policy, she was diagnosed with chronic Kidney

disease for which she underwent renal transplant in the year 2019. Out of the total

hospitalization expense of Rs. 7 Lakhs incurred by her, the erstwhile insurer Apollo Munich had

settled her claim for an amount of Rs. 5 Lakhs while failing to honor the cumulative bonus

accrued against the policy as well as the benefits which were payable under the opted critical

illness cover. Since the representation given to respondent who had taken over Apollo Munich

insurance company in the meantime had failed to give a satisfactory reply to her, the

complainant had therefore sought justice from this Forum.

18) Cause of Complaint: Non-settlement of cumulative bonus against the claim made and also

the benefit against the opted critical illness cover payable under the medical Insurance policy.

a) Complainant’s argument: In her letter addressed to this Forum, the complainant had stated that she had taken a medical insurance policy through her intermediary on 16.07.2016 with a sum insured of Rs. 5 Lakhs along with an optional critical illness with sum insured of Rs. 1 Lakh. Cumulative bonus for the sum insured of Rs. 5 Lakhs shall be automatically increased by 10% in the next renewal period as the policy was renewed till the year 2020. She was diagnosed with Chronic Kidney Disease (CKD) in the year 2018 and had undergone renal transplant for the same on 22.06.2019. She was put on dialysis for one month which had cost her Rs. 35,000/- besides other treatment expenses which amounted to Rs. 70,000/-. She was hospitalized between 20.06.2019 and 29.06.2019 during which time the hospital had charged her Rs. 7 Lakhs. The medical reimbursement claim filed by her


was settled for Rs. 5 Lakhs only after replying to several enquiries made by the erstwhile insurer Apollo Munich. She had further stated that her consultant Nephrologist had cautioned her of the consequences post renal transplant since she was put under immune suppression tablets and had therefore advised her to be under self isolation for a minimum period of 1 year in order to avoid being exposed to infections. During the renewal of the policy, the respondent had contacted her to take a new product with the existing features since they did not continue their tie with Canara Bank. During such time, she had submitted her claim papers as per the respondent’s advice seeking the pending critical illness cover for Rs. 1 Lakh and also the accrued cumulative bonus but for which she did not receive proper response despite her several telephonic calls to the customer service center. b) Insurer’s argument: Self contained note was submitted by the respondent over mail dated 22.03.2021. The Complainant had filed Reimbursement Claim vide ID:1078294 for an amount of Rs.7,00,000/- for the hospitalization from 20-06-2019 till 29-06-2019 at Century Super specialty Hospital Pvt. Ltd. The claim was settled for an amount of Rs.5,00,000/- as per the Sum Insured under the Policy. The rest amount was not paid as the SI was exhausted. They were now willing to pay critical illness amount of Rs.50,000/-. 19) Reason for Registration of Complaint: The insurer rejected the claim preferred by the complainant. As the complaint falls under Rule 13.1(b) of Insurance Ombudsman Rules, 2017, it was registered. 20) The following copies of documents were placed for perusal: a. Policy copy b. Discharge summary c. Rejection letter d. Correspondence with insurer e. Self contained note with enclosures.

21) Result of the personal hearing with both the parties: Pursuant to the notices given by this Forum both parties attended the online hearing at Hyderabad on 22.03.2021. The complainant stated her claim for renal transplant was paid and that she was eligible for Rs.1 Lakh towards critical illness benefit and cumulative bonus as seen from the terms and conditions of her 2019-20 policy submitted to us. The respondent insurer informed of having already settled the CKD renal transplant claim for an amount of Rs.5 Lakhs being the maximum sum insured under the policy. Since group insurance policies do not have the facility of cumulative bonus, the same was not paid. However, they were willing to pay critical illness cover of Rs.50,000/- as shown on the face of the policy pertaining to 2018-19 since the insured underwent renal transplant on 20.06.2019 that falls within that policy period . The complainant has submitted 5 audio conversations held with officials of the respondent that are inaudible. She contended that she was informed by the officials of insurance company that she was eligible for one lakh each under bonus as well as critical illness cover. The respondent insurer was asked to submit copy of the terms and conditions under both the policies and was further enquired as why there has been change in the nomenclature of the policy along with terms of coverage. The respondent insurer vide mail dated 23.03.2021 submitted the previous and current policy certificates along with respective terms and conditions. The complainant was issued Easy Health group insurance policy from 16.07.2016 which was renewed annually till 15.07.2019. In the policy period 16.07.2018 to 15.07.2019 the optional critical illness cover is mentioned as Rs.50,000/- and there is no cumulative bonus coverage on the face of the policy or under the terms and conditions . Subsequently, the product was upgraded by the Respondent Insurance Company and a policy was issued effective from 16.07.2019 to 15.07.2020, wherein it is observed that Optional Critical Illness sum insured of Rs.1 Lakhs and cumulative

bonus sum insured is kept blank. From this it is given to understand that this upgraded product contains cumulative bonus i.e., 10% increase in her annual inpatient benefit sum insured for every claim free year, subject to a maximum of 100%. When the complainant does not make a claim under the revised policy commencing from 2019-20 during the next renewal she would be eligible for a cumulative bonus @ 10% every claim free year. Since this facility was not available under the 2016-19 Easy Health Group policies she therefore does not have the facility of accrual of cumulative bonus from the previous years under the upgraded 2019-20 Group Assurance Health plan policy. The complainant was hospitalized on 20.06.2019 which falls in the policy period of insurance between 16.07.2018 -15.07.2019. Since the optional critical illness cover is mentioned as Rs.50,000/- and there is no cumulative bonus under that policy, the complainant is therefore entitled for only Rs.50,000/- towards critical illness coverage. Hence the claim of the complainant is partially allowed.

A W A R D Taking into account the facts & circumstances of the case and the submissions made by both the parties during the course of the personal hearing and the information/documents placed on record, the insurer is directed to settle the claim for Rs.50,000/- under optional critical illness coverage. The complaint is partially Allowed.



v) According to Rule 17(6), the insurer shall comply with the award within 30 days of the receipt of the award and intimate compliance to the same to the Ombudsman.

w) According to Rule 17(7), the complainant shall be entitled to such interest at a rate per annum as specified in the regulations, framed under the Insurance Regulatory & Development Authority of India Act from the date the claim ought to have been settled under the Regulations till the date of payment of the amount awarded by the Ombudsman.

x) According to Rule 17 (8), the award of Insurance Ombudsman shall be binding on the Insurers.

Dated at Hyderabad on the 23rd day of March , 2021.

( I. SURESH BABU )

OMBUDSMAN



PROCEEDINGS BEFORE




Case between: SRI RACHAPUDI KUMARESHWARA AKHIL………………The Complainant

Vs

M/s Manipal Cigna Health Insurance Co. Ltd…………The Respondent



1. Name & address of the complainant Mr. Rachapudi Kumareshwara Akhil

H.No. 15-82, Ummaiah Street, Gollapudi,

Vijayawada

Andhra Pradesh – 521 225

(Cell No. 83330-83399)


23.07.2020 to 22.07.2021

Manipal cigna prohealth group insurance policy

23.07.2020 to 22.07.2021


Mr. R Sivarama Prasad & Mr R Kumareswara

Akhil

M/s Union Bank of India

4. Name of the insurer M/s Manipal Cigna Health Insurance Co. Ltd.

5. Date of Repudiation 19.10.2020 and 23.10.2020

6. Reason for repudiation Non-disclosure of material facts


8. Nature of complaint Claim pertaining to medical insurance policy


10. Date of Partial Settlement -----

11. Amount of Relief sought Rs. 576,874/- and restoration of policy





a) For the complainant SELF

b) For the insurer Ms. Swetha Nair – Legal Officer




The complainant’s mother had purchased an annual medical insurance policy for her, her husband and

the complainant from the respondent company. During the policy period, both the complainant and his

father were admitted at Vijay Orthopaedic & Accident care to undergo treatment for acute severe viral

pneumonitis. The respective claims towards the hospital expenses were filed with respondent company.

Since the respondent company had rejected the claims, the complainant had filed a complaint against

them in this Forum and also to seek the Forum’s intervention to resolve his complaint favorably.

18) Cause of Complaint: Repudiation of claims made under the medical Insurance policy.

a) Complainant’s argument:

The complainant had stated that the hospital expense of his father’s treatment was Rs. 396,830/- and that of his was Rs.180,044/-. His contention was that his mother had purchased an insurance policy from respondent on 23.07.2017 as per the solicitation of M/s Union Bank of India. Prior to this insurer, they had been covered continuously with M/s the New India Assurance Co. Ltd. for many years. The current policy was with the respondent company but they never received the insurance policies from them. He had contended that denial of claims of his and his father’s was not fair on the basis of the contents filled in proposal form because the marketing official of respondent had assured them that it shall be filled in by their sales staff and had asked them to sign on the blank proposal from which was duly complied with. Since they did not receive the policy copy from this respondent company, they were not aware if the proposal form filled in was attached to and formed a part of the policy or not. Since they were not aware of the existence of the proposal Form all these 3 years of their continued patronage with respondent, denial of future claims on the basis of proposal form was not known to them until the current claim was lodged which being the first of its kind. When it was requested of respondent to share the proposal form after the claims were rejected, no response was forthcoming from them. He had also contended that the treatment given to him and his father had no relevance to the medical conditions, diabetes or hypertension and it was not as though these two medical conditions had impacted the treatment of his father. He had also raised a point that even if there was any misrepresentation in respect to that of his father’s medical history, the claim of the complainant which was independent of that of his father ought not to have been repudiated on technical grounds. The act of respondent was one of malafide nature who had denied the genuine claims even though there were no claims reported to them for the past 3 years. Every communication made with respondent company met with a stereotypical response which had proved to be vexatious. b) Insurer’s argument: As per the self contained note submitted by the respondent, the claims of the insured members were not payable for the following reasons: The complainant’s mother by virtue of being an account holder of the master policy holder, namely, M/s Union Bank of India, was eligible to be enrolled under the master policy. The complainant’s mother had submitted the proposal form bearing No. 100100095834 dated 23.07.2017 through the master policy holder. The respondent had issued a certificate of insurance on the basis of reliance placed upon the information provided in the proposal form and as per the requirement of the complainant’s mother to enroll the complainant, his mother, and his father. The policy documents along with the copy of proposal form and the terms & conditions were duly delivered to the complainant’s mother at her registered address. The welcome letter delivered to the complainant’s mother along with the policy documents specifically stated that the same should be checked carefully to make sure that all the details were correct. The policy schedule further read:”This policy has been issued on the information provided by you on the proposal form. Attached with this policy schedule are the policy terms and conditions and annexure. Please ensure that these documents have been received, read and understood. If any of these documents have not been received, please contact our Customer service at the below mentioned details at the earliest. In case you find any discrepancy in the same, please contact us immediately.” The insured however had not notified the respondent of any discrepancy in the proposal form or in the policy documents. There were two claims registered, one of complainant’s and the other of his father. On scrutiny of claim documents submitted, the complainant’s father had been a known case of diabetes from 11 years and hypertension from 10 years and this medical history was not disclosed at the time of purchasing the policy of insurance. Moreover, if the answer to the questions asked under the medical and lifestyle information was YES, proposal was not eligible to be enrolled under the policy and request would have been made to the proposer to purchase a retail health insurance policy. The respondent had submitted that the master policy was so designed to provide low cost health cover to their customers who did not have any adverse medical history. Therefore, the policy of insurance which was priced low would not have been offered to those with any medical conditions. The intention of the proposer was malafide because she wanted to avail of the cover at a low cost which would not have been possible if there was a disclosure of medical history of any of the insured members. The claim was rightly denied and policy thus cancelled by invoking the policy clause VI.1-Duty to disclosure which reads:” The policy shall be null and void and no benefit shall be payable in the event of untrue or incorrect statements, misrepresentation, mis-description or non-disclosure of any material particulars

in the proposal form, personal statement, declaration, claim form declaration, medical history on the claim form and connected documents, or any material information having been withheld by you or anyone acting on your behalf, under this policy. You further understand and agree that we may at our sole discretion cancel the policy and the premium paid shall be forfeited to us.”

19) Reason for Registration of Complaint: The insurer rejected the claim preferred by the complainant. As the complaint falls under Rule 13.1(b) of Insurance Ombudsman Rules, 2017, it was registered. 20) The following copies of documents were placed for perusal: a. Policy copy b. Discharge summary c. Rejection letter d. Correspondence with insurer e. Proposal and portability forms. f. SCN and other supporting documents. 21) Result of the personal hearing with both the parties: Pursuant to the notices served on both the parties by this Forum both the complainant and respondent

were present on the scheduled date of on line hearing to air their points in their defense.

Besides what has been stated by the complainant in his letter addressed to the forum, he had

highlighted that the executive of respondent company had noted all the details in a blank paper to be

filled in later in the proposal form and therefore had compelled his mother to sign in the blank proposal

form. The complainant has further stated that both he and his father were hospitalized in view of covid

infection. Since the pandemic has affected one and all, irrespective of their medical conditions, the

alleged non disclosure by the proposer was irrelevant to the claims being repudiated by the respondent.

The respondent insurer has emphasized the facts as mentioned in their SCN. The forum asked the

respondent if non-disclosure of PED would amount to the repudiation of claim which is related to Covid,

to which, the respondent has stated that the claim will be dealt purely as per the terms and conditions

irrespective of whether the insured suffers from Covid or otherwise. In this regard, the forum has asked

the respondent to produce the signed enrolment form to take an appropriate decision while at the same

time, the complainant too was asked to produce medical records to show that the diagnosis namely viral

Pneumonitis is the other name for Covid.

The forum after hearing both the sides has made the following observations:

The complainant has submitted the enrolment form besides other documents at the time of filing a

complaint against the respondent insurer. The enrolment form submitted by the complainant and that

submitted by respondent are one and the same. However, both these documents do not contain the

proposer’s signature. Since the signed proposal form shall be the binding document to the contract of

insurance, the Forum had insisted upon the same from the respondent insurer. The respondent insurer

in their reply has mentioned that “the proposal form and premium amount is deposited by the proposer

with the Master Policy Holder, namely the banker subsequent to which the Certificate of Insurance is

issued on the basis of the information provided in the proposal form and upon receipt of premium.

Certificate of Insurance is issued solely on the basis of the Good Health Declaration provided under the

proposal form. There is no medical underwriting involved in the issuance. In case of a disclosure of

medical history in the proposal form, the proposal is a direct reject."

The Forum has also raised a question as to any documentary proof the complainant could produce in

support of his claim that his mother who was the proposer of the insurance policy had no deliberate

intentions to suppress the material facts at the time of purchasing the insurance policy. In response to

this question, the complainant has mentioned that the disclosure of PEDs to the previous two insurers

namely, M/s Star Health and M/s The New India Assurance by itself was sufficient enough to prove that

the intention of the insured was not one of concealment of facts as alleged by the respondent insurer. In

this regard, the Forum notes that the proposer to the insurance purchased from the previous two

insurers is the father of complainant whereas, the proposer to the insurance procured from the

respondent insurer through the intermediary is the complainant’s mother. Since the proposers are

different, the intention of one proposer does not necessarily determine the intention of the other

proposer. Moreover, the current insurance policy is not considered to have been ported because the

previous two policies of insurances with the pervious insurers are individual policies and the present

policy of insurance is a group policy. Therefore, the respondent insurer cannot be said to have any

knowledge of the PED of the insured member as the platform of operations of these products of

insurances are different from each other and are not in the reach of public domain for the respondent

insurer to be able to access them. Hence, this proof submitted by the complainant cannot be considered

in his favor.

Since, the question of porting is ruled out as concluded from the above paragraph, the issue boils down to the veracity of enrolment forms submitted by both the parties independently of each other. As regards the blank proposal form signed by his mother and which the complainant himself avers, it is to be understood that an insurance product like any other product is a saleable product except that it is different from the other commodities because of its intangible nature. The complainant therefore cannot plead innocence that the person/an entity who/ which has solicited his mother to buy an insurance product is/ are solely responsible for obtaining the consent on a blank proposal form. The views of the complainant and the respondent therefore converge in as much as the enrolment form being signed by complainant’s mother is concerned- be it a blank or a filled one, and therefore the Forum concludes that no insurance contract is possible in the absence of a written consent from the proposer. The crux of the issue therefore boils down to the conflict that has arisen in respect of the data captured in the unsigned electronic enrolment form. The enrolment form issued for customers of M/s Andhra Bank, which is presently M/s Union Bank of India contains a specific column –Medical and life style information containing 2 questionnaires Have you are or any of the proposed insured members (1) ever suffered from, taken treatment, been hospitalized or been recommended to undergo investigations/ surgery/ take medication in the past 48 months for any ailment other than for childbirth, malaria, dengue, flu, or for completely healed minor injuries? (2) Suffered or currently suffering from any pre-existing illness/ disease/ injury/ disability/ physical or mental defects/ or any condition that may affect mobility/ sight/ hearing/ speech? - The answers to both the questions are mentioned NO by the proposer who is the complainant’s mother. In the Note mentioned below this column, it states that if the answer is YES to any of the above questions, the proposal is not eligible to be enrolled under this policy. The respondent insurer sticks to their ground that the proposer has suppressed the material facts by disclosing a wrong information based on which the respondent insurer has issued a policy which they would not have done so had the facts been made known to them by the proposer of insurance. On the other hand, the complainant who too has produced the same electronic enrolment form rebuts the allegations made by the respondent insurer to state that the respondent insurer has filled in the data to suit their convenience for obtaining premium and then

has used the same information to their advantage to once again deny the legitimate claim of his father on alleged grounds of material non disclosure cited by respondent. In this regard, the Forum feels that due diligence has not been exercised by the proposer of insurance who has given an authorization to her banker to debit the premium amount without exercising her right to know the contents in the proposal form. Thereafter, neither has the complainant/ any of the insured members made any effort to communicate in writing to the banker nor to the respondent insurer regarding the non availability of the policy certificate and the enrolment form in the first year of inception of insurance. The forum also does not agree that the complainant was not having any knowledge that he should demand for his right to know the contents filled in the enrolment form because neither the complainant nor the other insured members are new to an insurance policy as is obvious the way the complainant could produce the enrolment form from his previous insurer and the concept of portability etc. The complainant himself has stated that he had received the unsigned enrolment form from the respondent company at the time of first renewal of policy. It is to be noted that the claim made by complainant’s father falls in the second renewal year of the policy. Hence, the complainant was in possession of the information captured in the enrolment form and he could have immediately raised the issue with the banker or with the respondent insurer to get it corrected. Since he had failed to do so, it is very clear that the proposer of insurance including the complainant had a definite intention to suppress the material facts regarding the PED of complainants’ father owing to the fact that the premium charged/ features available under this insurance being more favorable to them. The forum also would like to place on record that if the proposer of insurance in the current policy had been the father of complainant, benefit of doubt could have been given to complainant because of the antecedent of his father who being the proposer in the previous insurance policies with previous insurers had honestly disclosed the PEDs with those insurers. As regards the argument raised by the complainant that the current ailment of his father for which a claim was lodged with respondent insurer has no relevance with the PED namely Diabetes, it is to be understood that a contract of insurance is based on the principles of utmost good faith. The policy being a group insurance policy where the insurer factors the premium based upon a huge customer base therefore has the right to deny any claim by invoking the duty to disclose norm as it is the only powerful weapon given in their hands by their regulator. Further, concealment of facts does hamper the judiciousness of an underwriter to take an appropriate decision to underwrite such risks. Since this opportunity has not been given to respondent insurer, the insurer has issued the policy which they have rightly cancelled once the facts came to their knowledge. In response to the complainant’s argument that the hospitalization claim of his and if not of his father’s at least be considered where there is no past medical history, the Forum finds this argument bizarre because the enrolment form which is also in possession of the complainant is self explanatory and that being the proposal itself is not eligible to be enrolled in the policy. Therefore, not only the complainant’s father but the entire family members would have been denied this specific group policy cover. The Forum therefore finds no frailty in the decision taken by respondent to deny the claim and thus cancel the policy subsequently.

A W A R D Taking into account the facts & circumstances of the case and the submissions made by both the parties during the course of the personal hearing and the information/documents placed on record, the complaint is devoid of merits and is therefore DISMISSED. The complaint is DISMISSED.

Dated at Hyderabad on the 31st day of Mar, 2021.

( I. SURESH BABU )

OMBUDSMAN



Insurance Ombudsman

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