A Delhi man who spent months pursuing a health insurance claim after losing his wife to illness has secured relief from a consumer commission, which held that an insurance company failed to justify major deductions made while settling his claim.
The order came on a complaint filed by Pravash Mohanty, who approached the consumer commission after receiving only a fraction of the hospital expenses incurred during his wife’s treatment in 2020.
According to the complaint, Mohanty and his wife were covered under a family health insurance policy valid from April 1, 2020, to March 2021, with an insured sum of Rs 3 lakh.
The case arose after his wife travelled to her hometown of Bhubaneswar, where she fell ill. She was admitted to a hospital on June 20, 2020, and discharged four days later after her condition failed to improve. Two days later, she was admitted to another hospital, where she remained under treatment until July 3.
Despite being discharged, her health did not recover and she died on July 17, 2020.
The two hospitals together raised bills amounting to Rs 3.08 lakh. However, the insurance company reimbursed only about Rs 91,000. Mohanty told the commission that repeated requests for payment of the remaining amount yielded no result, forcing him to seek legal recourse.
In his complaint, he sought reimbursement of Rs 2.08 lakh and compensation for the mental distress and harassment caused by the dispute.
National Insurance Company Ltd contested the claim through its counsel, arguing that there was no deficiency in service and that the complaint was not maintainable. The insurer maintained that the claim had been settled strictly in accordance with policy terms and conditions.
The company argued that deductions were made under various policy clauses and preferred provider network (PPN) rates. It also contended that the complainant had chosen treatment in a non-PPN hospital despite the availability of a PPN hospital in the area in Odisha, making the deductions permissible under the policy.
After hearing the matter, the consumer commission, comprising President Sukhveer Singh Malhotra and Member Ravi Kumar, found that the insurer had failed to satisfactorily justify the deductions made from the claim amount.
In its order dated June 1, the commission directed the insurance company to pay Rs 1,65,266 to the complainant. It further ordered payment of Rs 20,000 as compensation, carrying interest at 9 per cent per annum from the date of filing of the complaint, along with Rs 10,000 towards litigation expenses.
