The permanent Lok Adalat here pulled up an insurance company for rejecting a mediclaim on the ground that hospitalisation was “unnecessary” and directed it to reimburse Rs 81,322, with interest, to a city resident.
The Bench also asked United India Insurance Company Limited to pay Rs 5,000 as compensation for mental harassment and litigation expenses.
The order was passed by the Bench — comprising chairperson Preeti Sahni and member Rakesh Satija — in a complaint filed by Bhushan Kumar Gupta, a resident of Aggar Nagar Enclave. The complainant also nominated Raksha Health Insurance TPA Private Limited in the complaint.
According to the information, the applicant had a family policy with the insurance company for more than 10 years, and was regularly paying premiums. He renewed the policy in December 2022 after paying a premium of Rs 40,054 for coverage of Rs 7 lakh.
The applicant said that on August 18, 2023, he suddenly lost consciousness and was taken to Dayanand Medical College and Hospital (DMCH), where doctors advised hospitalisation. He was admitted till August 22, 2023, and incurred substantial medical expenses.
However, the cashless mediclaim request was rejected by the insurance company, citing hospitalisation was not required and he could have been treated in the Out-Patient Department (OPD).
During the proceedings, counsel for the insurance company relied upon the report of a doctor engaged by the TPA, who opined hospitalisation was unjustified. The applicant, on the other hand, argued he was admitted under supervision of a senior gastroenterology specialist and the treating doctors were the best judges of whether hospitalisation was necessary.
Agreeing with the applicant’s contention, the permanent Lok Adalat held that when a person falls ill, he immediately approaches doctors and hospitals, and the treating doctors are the best persons to assess requirements of hospitalisation.
The Bench added insurance companies have made it a “routine” to reject even genuine claims. It observed nobody liked to remain admitted to a hospital merely to claim insurance benefits, and termed the repudiation of the claim as “unjustified”.
During the hearing, the insurance company referred medical bills to Raksha TPA for assessment. After scrutiny, the TPA calculated an admissible amount of Rs 81,322, though it again sought to deny the claim citing policy exclusions.
Rejecting the plea, the Bench directed United India Insurance Company to pay Rs 81,322 to the applicant, along with interest at the rate of six per cent per annum, from the date of filing of the application till realisation.
