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| SCDRC directs NIC to pay claims in 3 cases | | | EARLY TIMES REPORT
JAMMU, Oct 09: Awarding justice to the complainant in a case related to the reimbursement of medical insurance, chairman of the state consumer disputes redressal commission (SCDRC), Justice (retired) G D Sharma has directed National Insurance company (NIC) to indemnify the complainant against his three claims of Rs 1,44,972, 26,250 and
65,100 along with interest at the rate of 8 pc per annum from the date of filing of the complaint till the final payment was made.
An order, dated February 19, 2010, passed by divisional forum, was taken in appeal whereby the complaint of the appelant had been dismissed on the ground that the ailment from which he was suffering had insurance cover under the insurance policy to avail treatment only as an outdoor patient.
Justice Sharma noted in his order that the rightful claims of the appelant had been unlawfully denied by the respondents by adopting an attitude which smacked of malice and arbitrariness. His two claims being an indoor patient and one claim being an outdoor
patient were rejected on whimsical grounds which had no baring on the terms and conditions of the insurance policy. According to the complaint, Galdan Wanchuk had obtained medico claim insurance policy bearing No 420806/48/03/8500962 which came into operation on February 24, 2005, and had to expire on February 23, 2006.
The case of the appellant is that during the policy period, he developed the disease of majr depression disorder with suicidal tendencies.
For some time, he was examined in government medical college hospital, Jammu. Thereafter, for the sake of availing specialised treatment, he was taken to south point hospital, New Delhi. There, he remained as an indoor patient from January 20, 2005 to February 4, 2005. The appelant through his mother, Dr P Angmo raised the
insurance claim.
Respondent No 1, being the third party agent authorised and licensed by IRDA vide their letter dated February 23, 2005, informed Dr P Angmo that as per the opinion received from their medical team the claim did not fall under the purview of the policy for the reason the treatment could have been taken as an outpatient. The claim was
for the reimbursement of Rs 1,44,972 and the same was repudiated. Afterwards, the appelant got his medical treatment as an outdoor patient in Delhi from Sanjay Chugh and paid him the consultation fee and other charges on three occasions totalling Rs 26,250.
After some time as signs of disease re-occured, the appelant was given medical treatment in SUNTULAN which is specialised centre for management of psychiatric and alcoholic/drug problem situated in Delhi.There he remained as an indoor patient from November 3, 2005 to December 3, 2005. The expenditure incurred for getting treatment
was Rs 65,100. This claim was also raised but he was not paid as it was also sent for getting panel report from the approved panel of doctors. According to the panel report prepared by Dr Sayed Manzoor, the present hospitalisation is found to be not necessary and outpatient treatment is sufficient in this case. As per the policy terms and conditions treatment, which requires hospitalization, is only payable. Hence the claim is not payable.
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