BENGALURU: In what could come as a major relief for those claiming medical insurance, a consumer forum in the city has ruled that insurance companies cannot deny claims if the claimant is unable to furnish original medical reports like inpatient case papers and operation notes.
The forum further ordered the insurance company to reimburse the claim amount along with interest and compensation. According to the order, passed by the IV Additional District Consumer Disputes Redressal Forum, the Oriental Insurance Company and Raksha TPA Private Limited will have to reimburse the claimant, Kumara Raju (name changed), Rs 69,069 with a yearly interest of 9 percent from July 2015.
In addition, the court also awarded compensation of Rs 10,000 and asked the companies to pay `10,000 towards costs of litigation.
In their order, the forum, comprising of President RK Prathibha and member NR Roopa, the forum noted that there was deficiency in service on the part of the companies. “Without looking into the facts, finally, Raksha TPA Private Limited issued a letter dated July 7, 2015, rejecting the claim of the complainant illegally,” the forum noted.
When the claimant asked the companies to visit the hospital to check the originals and settle the claim amount, they did not heed his request. “Refusal on the part of opposition parties to look into the original records and settle the claim benefit is unsustainable,” the forum said.
The complainant, a resident of Shastrinagar, had obtained a Mediclaim policy from the Oriental Insurance Company for him and his wife. She was admitted to a private hospital at Basavanagudi and treated as an inpatient from December 16 to 19 in 2014 for various health issues. The complainant raised a claim for reimbursement with Raksha TPA Private Limited and the company sought certain documents.
However, the hospital told Kumara Raju that it was not their policy to provide original documents. They offered copies of the documents, which Raju forwarded, asking the company representative to visit the hospital to confirm the authenticity of the copies. But he did not get a reply nor was he reimbursed in spite of many reminders, forcing him to approach the forum.
While the Oriental Insurance Company defended the rejection claim, representatives of Raksha TPA Private Limited did not appear before forum though notice was served.