CHENNAI: A city consumer forum has directed United India Insurance to pay a compensation of Rs 25,000 to a health insurance policy holder for denying him the full sum, even after he produced bills for the claim.
The company has been directed to pay the policy holder Rs 48,509 towards the claim amount in addition to Rs 25,000 as compensation.
The complainant, S Kanhayalal Jain, moved the forum stating that as his wife was diagnosed with cataract in her right eye, she underwent surgery on December 28, 2013 and was discharged on January 11, 2014. Jain made a mediclaim of Rs 48,509 towards the expenses incurred by him. However, the insurance company restricted her claim to Rs 20,450 on January 29, 2014 quoting an exclusion clause, and the sum was not accepted by Jain as he wanted the entire claim amount.
The insurance company on their part said that Jain had an individual health policy from July 19, 2013 to July 18, 2014 covering himself and his wife. It stated that the cover under the policy was only for ‘reasonable expenses’ and that any ‘excess or unnecessary expenses’ could not be claimed.
“The complainant claim was processed by the TPA (third party administrator) and it was found that the bills during hospitalisation and doctors fee were allowed as claimed and the cost of lens was found to be in excess of the normal costs and the complainant had chosen multifocal lens instead of normal lens and TPA allowed Rs 8,000 as against Rs 34,000,” the insurance company said. “Accordingly, TPA allowed Rs 20,450 towards reasonable and necessary charges for the treatment.”
However, the District Consumer Disputes Redressal Forum, Chennai (North), presided over by President K Jayabalan, dismissed this argument on May 24. “The 3rd party administrator (TPA) has not issued the policy to the consumer/complainant,” the forum said. “Hence there is no privity of contract between the complainant and the TPA in respect of policy issued by the opposite party and therefore, the TPA has no right to decide the claim based on the policy issued to the complainant. If at all the TPA can only collect claim papers from the consumers and place before the opposite party for the decision and he cannot take any decision.”
The forum said that the choice of lens could not be a point of contention. One cannot restrict a patient to chose any particular lens. By awarding Rs 8,000, the opposite party has committed deficiency,” the forum said. The opposite party has not applied its mind in considering the mediclaim made by the complainant. By accepting the conclusion of the TPA and allowing the TPA to decide the claim, the opposite party has committed deficiency in service, the forum noted.