The District Consumer Disputes Redressal Forum II here has ruled in favour of a person whose claim for reimbursement of medical expenses under a United India Insurance scheme was rejected.

Vandana Gautam said she had undergone a hysterolaproscopy at the Femina Women’s Hospital, and was billed a sum of Rs. 48,865 for it. She claimed reimbursement under the Mediclaim Insurance Scheme provided by the Indian School of Business, where her husband worked.

The policy was valid at the time of the procedure, and the claim limit was Rs. 5 lakh. Yet, her claim was rejected.

United India Insurance Co. Ltd denied the claim on the grounds that Vandana was treated for infertility as per the records. However, the patient contended that the anaesthetist had wrongly entered the particulars as ‘infertility’.

She said she had got a statement from the doctor who treated her, saying that “The anaesthetist inadvertently mentioned in the diagnostic column as primary infertility instead of diagnostic hysterolaproscopy for pelvic endometriosis.”

The insurance company then alleged that the claimant had had the discharge summary altered to accommodate the claim.
After perusing all the documents, the forum ruled in favour of Ms. Vandana, and directed United India Insurance to pay her the cost of the procedure, along with interest at 9 per cent per annum, till the date of payment, plus Rs.5,000 as costs.


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