Ludhiana | Insurance company to reimburse medical claim of ₹2,000,000

For his failure to reimburse a claim for reimbursement of medical expenses 2 lakh to a patient, the District Consumer Dispute Redress Commission on Sunday ordered Reliance General Insurance Company Ltd to release the claim and pay 7,000 compensation to the plaintiff.

Mohit Sharma of Ludhiana had filed a complaint against the branch manager of the opposing party (OP), Reliance General Insurance Company Ltd, Ludhiana, alleging service deficiency.

Sharma purchased a medical policy from the PO in August 2015, which has been renewed from time to time. The plaintiff’s wife and minor son were also covered by said policy.

On December 12, 2019, the plaintiff was admitted to the SPS Hospital in Ludhiana due to a major heart attack.

The complainant remained admitted until December 14, 2019.

Since there was no cashless service, the complainant spent an amount of approximately 2,00,000 on his salary.

After being discharged from the hospital, the plaintiff applied for reimbursement of the claim and submitted all the necessary documents with the said insurance company. Mohit said his application was rejected by the PO and the policy was also canceled on the grounds that the former did not disclose in the proposal form that he had diabetes.

The plaintiff asked the PO to provide him with the application form and other documents, but the insurance company refused to do so, Mohit alleged.

Consequently, the complainant requested reimbursement of the total invoice for 2.02 lakh with the compensation of 5,000,000.

However, refuting the allegations, the insurance company argued that the complaint was false and frivolous.

“The claim was not payable as the claimant had been a known case of diabetes mellitus since 2011 and was undergoing regular treatment for said disease, but this fact was not disclosed by the claimant in the proposal form at the time of creation of the policy,” the insurance company’s attorney said.

In the meantime, the Commission observed in its order: “It is a settled proposition of law that diabetes mellitus and hypertension are common diseases and it is not necessary that anyone suffering from hypertension and diabetes Sweet also suffers a heart attack. Even otherwise, in this case, the factum of non-disclosure of a pre-existing condition of diabetes mellitus has not been established by the opposing party. In these circumstances and given that the proposal form was not registered by the PO, it must be considered that the rejection of the application by the PO is not justifiable and that the latter is likely to be cancelled”.

The Commission further ordered the PO to consider and reimburse the claim relating to the complainant’s hospitalization from December 12, 2019 to December 14, 2019, strictly in accordance with the terms and conditions of the policy, and also to pay a set of 7,000 to the plaintiff.