THIRUVANANTHAPURAM: A woman whose health insurance claim was rejected by Reliance Insurance Co Ltd “for want of essential documents” got relief from the State Consumer Disputes Redressal Commission (SCDRC). Interestingly, it was two letters submitted by the company that helped the commission reject its argument.
SCDRC’s order came on an appeal petition filed by the company against the favourable verdict obtained by the woman and her husband from the Kasaragod District Consumer Disputes Redressal Commission. SCDRC upheld the district commission’s order and directed the company to pay Rs 1.39 lakh towards settlement of the claim with 6% interest. It also upheld the directive to pay Rs 25,000 as compensation and Rs 5,000 as costs.
The order was issued by a bench comprising SCDRC judicial member Ajith Kumar D and member Radhakrishnan K R.
The couple hailing from Hosdurg, in Kasaragod, had taken the ‘Reliance Care For You’ plan with a sum insured of Rs 2 lakh for a period of three years from September 7, 2013. The first instalment of Rs 13,491 and subsequent premiums were paid regularly.
In July 2015, the woman was hospitalised at Father Muller Hospital, Mangaluru, with polypoidal growth sigmoid. She shifted to MIMS Hospital, Kozhikode, a few days later for better treatment and underwent surgery there.
She ended up paying Rs 10,205 at Father Muller and Rs 1,29,459 at MIMS. And she placed a insurance reimbursement claim for Rs 1,39,664. The Reliance Insurance counsel argued that the claim was not settled because the woman failed to submit essential documents, including original hospital bills, investigation reports, discharge summary, etc.
He produced two letters sent by the third-party administrator (TPA) to the complainant to facilitate claim settlement. Both the letters were dated July 14, 2016. One letter listed five requirements while the other listed two.
The two requirements in one of the letters were: “(1) provide all original pre-numbered paid receipts of hospital bill Rs 1,29,459 and (2) We have received incomplete query reply.” From this correspondence, SCDRC concluded that the hospital bill for Rs 1,29,459 was the only document that had not been submitted. She had produced discharge bills totaling Rs 1,39,614 towards treatment expenses in both hospitals.
The commission said the documents produced by the woman were sufficient to conclude that she was treated for the illness and had spent the amount claimed. It directed Reliance Insurance to abide by the district commission’s award.