The complaint of a mediclaim policy holder who was denied reimbursement of hospital charges has been upheld by the Chandigarh State Consumer Disputes Redressal Commission.

The Commission has directed the New India Assurance company to pay Rs 98,000 to Simrit Kaur for refusing to reimburse her for medical expenses incurred, citing ‘flimsy’ reasons.

Simrit Kaur had taken the policy for herself, her husband, daughter and son, for a sum of Rs 5 lakh each, and had been regularly paying premiums. She made a claim after she was hospitalized for surgery. She incurred an expenditure of over Rs. 1.10 lakh, but though she had been promised a cashless facility, the convenience was extended to her only to the extent of Rs. 30,000.

The claim was also not paid in full, with the company refusing to reimburse various amounts on pretexts such as the absence of required reports.

The Commission noted that it was the responsibility of the company to obtain and verify documents and that the insured could not be put to a disadvantage on this account. There was also no clear-cut policy about the reasonability of claims, and in such a situation, the deductions that the insurance company had made on the claim were unwarranted.

The insurance firm has been ordered to pay Rs 81,000 with interest to Simrit Kaur, as well as Rs 17,000 as compensation for mental agony and harassment and litigation expenses.


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