Insurance company refuses the payment against hospitalization bills

920 votes

As per your query you can directly issue a legal notice to the Insurance company asking them for the payment of same amount that is the Hospital bills. Thereafter you can file a complaint before the consumer forum for deficiency of services and seek compensation from the consumer forum.

Regards

Advocate Neelkanth Goswami LawRato

560 votes

If there has been a refusal of insurance claim by the concerned insurance company on the ground that the matter is not covered under the terms of the insurance contract then the most appropriate relief is a civil proceedings. Typically you would be in a position to challenge the insurance company's refusal by application to the proper insurance authority under the Insurance Act or the IRDAI Act.
Additionally, it would also be a case of breach of representations and/or warranties under contract governed by Indian Contract Act.
The case would not actually be a breach service contract per se.
Even if an offence be lodged under the IPC in the end no remedy can be obtained because the object of proceedings under IPC is conviction and punishment. It will not automatically result in insurance company paying your claim amount. For that a civil or regulatory proceeding would be most appropriate course of action.
Whether or not the hospital expenses in question are covered under insurance policy of the company is a question of interpretation of the terms of contract which is contained in the policy document. For any practical legal advice it would be necessary to scrutinize the same and then strategize how to develop a legal argument for substantiating the claim - entitlement. That is one step. The next step would be to prove the claim, i.e. the computation of the amount. For this it woudl necessary to scrutinize the actual bills bearing in mind the scope / coverage of the insurance policy document and the amounts reflected in the bill. An Application would have to be filed with the concerned insurance authority for claim with legal representation.

Advocate Mrinalika Devarapalli LawRato