Insurance Company directed to pay Rs 50000 fine for refusing mediclaim

  • The apex consumer commission, asked an insurance company to compensate an 83-year-old doctor with Rs 50,000 for not providing him with the terms of his insurance policy and refusing him full mediclaim after he underwent a brain hemorrhage treatment.
    Dr J R Banik bought a mediclaim policy from National Insurance Company Limited in 2007. The company issued the insurance certificate with the coverage of medical expenses up to Rs 1 lakh but did not give the terms and conditions of the policy. While the policy was still in force, Banik suffered a brain hemorrhage and spent Rs 87,773 towards his treatment.

    "It appears that agents of insurance companies, in order to achieve a target number of insurance policies, act in haste to collect premium. The consumers are supplied either with the cover note or the insurance certificate without any policy clauses. If insurance companies take a little pain to provide terms and conditions along with the policy certificate, then there will be limited scope for litigation," the commission observed.

    It was alleged that when Banik filed a claim, the insurance company did not settle his claim entirely and proposed to pay only Rs 64,360 towards his treatment. The company asserted that the complaint was not maintainable as the deduction was strictly in accordance with the terms and conditions of the policy.

    The National Consumer Disputes Redressal Commission (NCDRC) said that Dr J R Banik had suffered "severe mental agony" and financial crunch due to the "arbitrary act" of the insurance company. "He was made to run from pillar to post to claim the balance amount. The complainant was never supplied with the terms and conditions of the policy, else he would have opted for the medical treatment within the terms of his policy," observed the commission.

    The commission upheld the decision of the district forum that had directed the insurance company to pay the balance amount besides asking it to pay Rs 50,000 as compensation and Rs 5,000 as litigation cost.

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