proceedings of the insurance ombudsman, delhi

PROCEEDINGS OF THE INSURANCE OMBUDSMAN, DELHI

(Under Rule 13 r/w 16 of the Insurance Ombudsman Rules, 2017)

Ombudsman: Shri Sudhir Krishna

Case of Nand Kishore versus The United India Insurance Company Ltd.

Complaint Ref. No.: DEL-H-051-2122-0269

1. Name & Address of the Complainant ShriNand Kishore House No. 128, IInd Floor, Pocket-17, Sector-24, Rohini, New Delhi-110085

2. Policy No. Type of Policy Policy term/policy period

5001002818P109891131 Group Health Insurance Policy 01.10.2018 to 30.09.2019

3. Name of the insured Name of the policy holder

Nand Kishore Indian Banks’ Association A/c Corporation Bank

4. Name of insurer The United India Insurance Company Ltd.

5. Date of repudiation 24.04.2020

6. Reason for grievance Rejection of post hospitalization Mediclaim

7. Date of receipt of the complaint 26.07.2021

8. Nature of complaint Rejection of post hospitalization Mediclaim

9. Amount of claim Rs.2,50,000/-

10. Date of partial settlement N.A

11. Amount of partial settlement N.A

12. Amount of relief sought Rs.2,50,000/-

13. Complaint registered under Rule No. of the Insurance Ombudsman Rules 2017

Rule 13(1)(b)- Any Partial or total repudiation of claims by an Insurer

14. Date of hearing 24.08.2021

Place of hearing Delhi, Online Video Conferencing via Cisco WebEx App

15. Representation at the hearing

For the Complainant Shri Nand Kishore, the Complainant

For the Insurer Smt. Pamela Pinto, Deputy Manager (LCD), Mumbai

16. Date of Award/Order Recommendation under Rule 16/ 24.08.2021

17. Brief Facts of the Case: Shri Nand Kishore (hereinafter referred to as the Complainant) has filed this complaint

against the decision of The United India Insurance Company Ltd. (hereinafter referred to as the Insurers) alleging wrong

rejection of post hospitalization Mediclaim.

18. Cause of Complaint:

a) Complainant's Argument: The Complainant was admitted in the Chetna Neuropsychiatry Hospital in emergency and

was diagnosed as a case of major depression. He was discharged from the hospital on 22.06.2019 and advised for day

care treatment from 24.06.2019 to 07.07.2019. During hospitalization, 8 sittings of electro convulsive therapy were

given. For continuous supervision of his health, hospital also advised him to attend weekly programme on 14.07.2019

and 21.07.2019. He claimed hospitalization bill from his individualHealth Insurance Policy & the same was settled by

them. As his Sum Insured was exhausted in the Individual Health Insurance Policy, he claimed post hospitalization

expenses from the subject policy. TheInsurers rejected his claim by citing many clauses i.e.5.D (Procedure to follow),

5.E.3(Authorization letter), 2.10 (Day Care center), hospitalization less than 24 hours and hospitalization not justified.

Further all these conditions were applicable for admission inhospital whereas he was claiming for post hospitalization

expenses.He approached the Grievance Cell of the Company but his claim was not settled.

b)Insurer's Argument: The Insurance Company, vide its Self Contained dated 22.07.2021, has stated that on

01.06.2019 the Complainant was taken to Chetna Neuropsychiatry Centre by his family members with c/o

restlessness, low mood, loss of appetite with gastric complaints. During hospitalization he underwent various series

of investigations. After hospitalization he was shifted to Day Care Centre from 24.06.2019 to 07.07.2019 and was

treated for depression. As per documents submitted, details were insufficient and were not evident for concluding

the payability of claim. Hence following quarries were raised:-

1. Pre numbered cash receipt for the amount collected from the patient on 24.06.2019 for Rs.2 lakh 2. Attested copy of Indoor case papers because as per final bill, period was from 24.06.2019 to 21.07.2019 whereas

as per ICP attached, period was from 01.06.2019 to 22.06.2019. 3. Clarification from hospital for making day care bill. 4. Detailed discharge summary in original.

Reply was received from the Complainant but no clarification was provided by the treating doctor. Hence claim was

repudiated as per Policy clause 5.D, 5.E.3, 2.9 & 2.10.

19. Reason for registration of Complaint: Rejection of post hospitalization Mediclaim.

20. The following documents were placed for perusal.

a) Copy of policy. b) Copy of GRO Letter, discharges summaries, bill, claim form, rejection letters. c) SCN of the Insurers along with enclosures.

21. Result of hearing with the parties (Observations and Conclusion):

Case called. Parties are present and recall their arguments as noted in Para 18 above.

At this stage, the Insurers offer to review the claim for the Daycare treatment undertaken by the Complainant from

24.06.2019 to 21.07.2019 in terms of the Bill No. 1514 of the Chetna Neuropsychiatry Centre and settle the same as per

the terms and conditions of the policy, within 30 days. The Insurers also agree to pay to the Complainant interest on the

settlement amount in terms of the provisions of the IRDAI (Protection of Policyholders’ Interest) Regulation 2017. The

Complainant accepts this offer. Thus an agreement of conciliation could be arrived at between the Complainant and the

Insurers, which I consider as fair and reasonable for both the parties.

Award

The complaint is resolved in terms of the agreement of conciliation arrived at between the Complainant and the

Insurers. Accordingly, the Insurers shall review the claim for the Daycare treatment undertaken by the Complainant

from 24.06.2019 to 21.07.2019 and settle the same as per the terms and conditions of the policy, along with interest

on the settlement amount, as mentioned above, within 30 days.

(Sudhir Krishna) Insurance Ombudsman, Delhi

PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATES OF A.P., TELANGANA & YANAM

(Under Rule 16(1)/17 of The Insurance Ombudsman Rules, 2017)

Ombudsman - Shri Suresh Chandra Panda

Case between: Mr. B SAIDULU……………The Complainant

Vs

M/s THE NEW INDIA ASSURANCE CO.LTD.,…………The Respondent

Complaint Ref. No. I.O.(HYD).H .049.2122.0226

Award No.: I.O.(HYD)/A/HI/0039/2021-22

. Name & address of the complainant

Mr. B.SAIDULU,Admn.Officer,

LIC of India, CITY BRANCH-12,

HYDERABAD,TELANGANA STATE—500 001.

MOBILE NO.94921 88655

2. Policy No./Collection No.

Type of Policy

Duration of Policy/Policy period

12070034200400000007

Group Medical Insurance Policy

01.04.2020 to 31.03.2021

3. Name of the insured

Name of the Policyholder

Ms.B pallavi, A/c.Mr.B.Saidulu

M/s.LIC of India

4. Name of the insurer

M/s. New India Assurance Co.Ltd.,

5. Date of Repudiation

21.05.2021

6. Reason for repudiation

Treatment does not require hospitalization

7. Date of receipt of the Complaint 07.06.2021

8. Nature of complaint

Complaint pertaining to repudiation of claim

9. Amount of Claim Rs. 61800/- approx

10. Date of Partial Settlement NA

11. Amount of Relief sought Rs.61,800/-

12. Complaint registered under

Rule No.13.1 (b) of Ins. Ombudsman

Rules, 2017

Rule 13.1 (b) – any partial or total repudiation of

claims by the Life insurer, General Insurer or the

Health insurer

13. Date of hearing/place 25.08.2021


a) For the complainant Mr,B Saidulu

b) For the insurer Dr.Kranthi Rekha

15. Complaint how disposed AWARD

16. Date of Order/Award 26.08.2021

17) Brief Facts of the Case:

The complainant and his family members are covered under the LIC Group Health Insurance policy issued by the

Respondent Insurer. During the policy period the daughter of the complainant was admitted in the Yashoda

Hospitals, Hyderabad for the treatment of fever and other complications. She has undergone investigations and

treated from 27/03/2021 to 31/03/2021 and incurred an amount of Rs.65,868/- during the hospital stay. The

complainant had lodged the claim for the reimbursement of the hospital expenses under the policy. However his

claim was rejected by the RI stating that the procedures/treatment undergone did not warrant hospitalization.

Aggrieved with the rejection of his claim the complainant had approached this forum for justice.

18) Cause of Complaint: Repudiation of claim by respondent under the medical Insurance policy.

a) Complainant’s argument: The complainant had stated that his daughter had been suffering from fever for more than three days, lost weight and became weak. On the advice of the pediatric doctor she was admitted in Yashoda Hospitals, Hyderabad for treatment. She was diagnosed with Acute febrile illness with under-nutrition and multi-nutrition deficiency and treated accordingly. Since the hospitalization is absolutely necessary for the treatment, the complainant had requested for the settlement of his genuine claim.

b) Insurer’s argument: The Respondent insurer had submitted the SCN and confirmed the Hospitalization of

the insured person Ms Pallavai with actute Febrile Illness, under-nutrition & multi-nutrition deficiency and

receipt of claim documents for reimbursement of the expenses for Rs.65868/- under the Group Health

insurance policy. They have stated that during the hospital stay the patient had undergone various

investigation tests and treated with IV fluids, multivitamins etc., and concluded that the treatment need not

warrant hospitalization and can be treated on OPD basis. Since the patient was mainly admitted for

investigations and the treatment given to the patient was possible on OPD basis the claim is not payable as per

Clause F Exclusion—Point No.x which read as follows:

“Charges incurred at hospital primarily for diagnosis, X-Ray or Laboratory examination or other diagnostic

studies not consistent with or incidental to the diagnosis and treatment of positive existence or presence of

any illness or injury, for which confinement is required at a hospital.”

19) Reason for Registration of Complaint: The insurer rejected the claim preferred by the complainant. As

the complaint falls under Rule 13.1(b) of Insurance Ombudsman Rules, 2017, it was registered.

20) The following copies of documents were placed for perusal:

a. Policy copy with terms and conditions

b. Discharge summary & Medical reports of Yashoda Hospitals

c. Correspondence exchanged

d.SCN and consent letter

f.ANNEXURE-VI-A

21) Result of the personal hearing with both the parties:

Pursuant to the notices given by this Forum both parties attended the OnLine hearing held on 25.08.2021 and

presented their arguments in support of their contentions. The complainant stated that his daughter was

admitted in the hospital on the advice of the pediatric doctor for treatment of fever and Loss of Weight. During

the hospitalization she was referred to various doctors, underwent investigations and treated accordingly. He

has stated that hospitalization is absolutely required for the said treatment and objected on the repudiation

of his claim on wrong premise. The insurer has argued that the treatment given to the insured person can be

done on OPD basis and does not warrant hospitalization. Since the treatment comes under policy Exclusion

the RI has justified the rejection of the claim.

Having heard the arguments and scrutinized the documents available, the Forum has observed that the insured

person was admitted in Yashoda Hospitals, Hyderabad on the advice of the consultant Pediatrician Dr. Pallavi

Bhukya. She was diagnosed with Acute Febrile Illness with undernutrition and multi-nutrition deficiency. She

underwent various investigations and referred to the doctors of Gynecology, Psychiatry, and Endocrinology

and treated for Primary amenorrhea, short stature etc., She was treated with IV Fluids, medicines and other

supportive treatment and discharged in a stable condition. In view of the above observations, the forum felt

that the insured person was hospitalized on the advice of the medical practitioner for investigations, evolution

and consequent treatment. The treatment given was in consistent and incidental to the diagnosis of

malnutrition, acute febrile illness etc.The administration of IV fluids and evolution by different doctors is not

possible as an outpatient.

In view of the above observations the forum felt that the rejection of the claim by the RI under the Policy

Exclusion No. F( x) is not consistent with the said policy exclusion. On careful study of the exclusion clause the

Forum felt that the clause is applicable only when the admission is primarily for diagnosis, x-ray or laboratory

examinations not consistent with or incidental to the diagnosis and the treatment of positive existence for

which confinement is required at a hospital. In the present instance, the insured person was admitted on the

positive existence of illness which is incidental and in consistent with the Laboratory examinations and other

diagnostic studies. The complaint has opted for hospitalization on the advice of the medical practitioner and

complied the policy condition A.1. under COVERAGES. Hence the Forum felt that the repudiation of claim under

Policy Exclusion No.F( x ) is not justified and violates the guidelines of the IRDAI on settlement of claims.

Under the circumstances of the case, the Forum finds that the repudiation of claim by the Respondent Insurer

is not in order and directs RI to settle the claim in accordance with terms and conditions of the policy.

Accordingly the Complaint is ALLOWED.

A W A R D

Taking into account the facts & circumstances of the case and the submissions made by both the parties during the course of the OnLine Hearing and the information/documents placed on record, the Respondent Insurer is directed to settle the claim as per the existing terms and conditions of the policy.

The complaint is ALLOWED.

22) The attention of the Insurer is hereby invited to the following provisions of Insurance Ombudsman Rules,

2017:

a) According to Rule 17(6), the insurer shall comply with the award within 30 days of the receipt of the award and intimate compliance to the same to the Ombudsman.

b) According to Rule 17(7), the complainant shall be entitled to such interest at a rate per annum as specified in the regulations, framed under the Insurance Regulatory & Development Authority of India Act from the date the claim ought to have been settled under the Regulations till the date of payment of the amount awarded by the Ombudsman.

c) According to Rule 17 (8), the award of Insurance Ombudsman shall be binding on the Insurers.

Dated at Hyderabad on the26 th day of AUGUST , 2021.

( SURESH CHANDRA PANDA )

OMBUDSMAN

FOR THE STATES OF A.P.,

TELANGANA AND YANAM CITY

PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATES OF A.P., TELANGANA & YANAM

(Under Rule 16(1)/17 of The Insurance Ombudsman Rules, 2017)

Ombudsman - Shri Suresh Chandra Panda

Case between: Mr. B SHANKARAIAH……………The Complainant

Vs

M/s THE NEW INDIA ASSURANCE CO.LTD.,…………The Respondent

Complaint Ref. No. I.O.(HYD).H .049.2122.0227

Award No.: I.O.(HYD)/A/HI/ 0040 /2021-22

1. Name & address of the complainant

Mr. B.SHANKARAIAH,

LIC of India, BHONGIR BRANCH OFFICE,

TELANGANA STATE—500 001.

MOBILE NO.93943 57306

2. Policy No./Collection No.

Type of Policy

Duration of Policy/Policy period

12070034200400000007

Group Medical Insurance Policy

01.04.2020 to 31.03.2021


Name of the Policyholder

Mrs.B Maheshwari A/c.Mr.B.Shankaraiah

M/s.LIC of India

4. Name of the insurer

M/s. New India Assurance Co.Ltd.,

5. Date of Repudiation

03.03.2021

6. Reason for repudiation

Claim falls under the exclusion clause F Vi of

policy



Complaint pertaining against repudiation of

claim

9. Amount of Claim Rs. 190,000/- approx


11. Amount of Relief sought Rs.190,000/-


Rule No.13.1 (b) of Ins. Ombudsman

Rules, 2017

Rule 13.1 (b) – any partial or total

repudiation of claims by the Life insurer,

General Insurer or the Health insurer

13. Date of hearing/place 25.08.2021


a) For the complainant Mr.B.Sankaraiah

b) For the insurer Dr.Kranthi Rekha

15. Complaint how disposed AWARD

16. Date of Order/Award 26.08.2021

17) Brief Facts of the Case: The complainant and his family members were covered under the LIC Group Health Insurance Policy issued by the Respondent Insurer. During the policy period his wife was admitted in Neelima Hospitals, Hyderabad with complaints of abdominal distension and swelling in supra umbilical area. She was diagnosed with Para Umbilical Hernia for which she underwent Laparoscopic Hernioplasty and discharged in stable condition. The complainant had lodged claim with the Respondent Insurer for the reimbursement of the expenses. However his claim was rejected by the Respondent Insurer stating that the cause of hospitalization comes under Obesity which was excluded under the policy exclusion Clause F Vi. However the complainant had represented that the present hospitalization of Para Umbilical Hernia was not related to Obesity and objected for applying the exclusion which was not relevant for the present illness and approached this forum for justice.

18) Cause of Complaint: Partial Repudiation of claim by respondent under the medical Insurance policy.

a) Complainant’s argument: The complainant had stated that he had admitted his wife for the treatment of

Para Umbilical Hernia and underwent Hernioplasty. He had spent Rs.190,000/- and applied for reimbursement

of medical expenses. However his claim was rejected on the grounds that Umbilical Hernia was occurred due

to Obesity which was excluded under the policy exclusion Clause F Vi. The complainant argued that his wife

was treated for Para Umbilical Hernia which was not connected with the Obesity and its complications. He has

also produced the Certificate from the Neelima Hospitals confirming that the treatment did not relate to

Obesity. He had reiterated that the treatment undergone by his wife was not related to obesity and its

complications and should not apply the policy exclusion Clause of F Vi. He had objected on rejecting the claim

on false pretexts and prayed for justice.

b) Insurer’s argument: The RI has submitted the SCN on 17/08.2021 and confirmed the admission of the

Insured person in Neelima hospital from 24/12/2020 to 01/01/2021 with chief complaints of abdominal

distension since 2 years, swelling in supra umbilical area, DM+,HTN+,History of LSCS. She was diagnosed with

Para Umbilical Hernia and underwent Laparoscopic Mesh Hernioplasty on 31/12/2020 and discharged on

01/01/2021. However, the RI had stated that the Umbilical Hernia can develop when fatty tissue or a part of

the bowel pokes through into an area near the naval and attributed the factors that can cause the Umbilicical

Hernia to overweight or obese, straining while moving or lifting heavy objects. Since the insured person was

an obese with morbid obesity(BMI >35) they have concluded that the main cause for the Paraumbilical Hernia

is obesity which comes under the policy exclusion clause F (vi) which states that the Company shall not be

liable for expenses connected with or in respect of “Convalescence, general debility, Run Down condition or

rest cure, OBESITY TREATMENT AND ITS COMPLICATIONS, congenital external disease/defects or anomalies,

infertility, sterility, use of intoxicating drugs/alcohol, use of tobacco leading to cancer.”

Hence the RI had justified the rejection of the claim as per the terms and conditions of the policy.

19) Reason for Registration of Complaint:

The insurer rejected the claim preferred by the complainant. As the complaint falls under Rule 13.1(b) of

Insurance Ombudsman Rules, 2017, it was registered.

20) The following copies of documents were placed for perusal:

a. Policy copy with terms and conditions

b. Discharge summary

c. Correspondence with the Insurer

d. ANNEX-VI-A

e.SCN

21) Result of the personal hearing with both the parties:

The Forum after perusing the complaint and relevant documents arranged the OnLine Hearing on 25.08.2021.

Both the parties have attended the Hearing from their respective places and submitted the arguments in

support of their contentions. During the course of the interaction the complainant has stated that the

treatment was not related to obesity and the claim is payable under the policy. However the RI has referred

the Medical journals and Reference Books and justified their conclusion of obesity as the proximate cause for

the present illness.

The Forum has carefully gone through all the documents placed before the forum and heard the arguments of

both parties. Based on the arguments and documents available with this forum it is observed that the insured

person was admitted in Neelima Hospital, Hyderabad with complaints of abdominal distention since 2 years

and swelling in supra umbilical area, DM+, HTN+, History of LSCS. She was diagnosed with PARA UMBILICAL

HERNIA and underwent Laparoscopic Hernioplasty. The complainant has lodged the claim with RI for the

reimbursement of the medical expenses incurred during the hospitalization. However the claim was rejected

by the RI stating that the insured person was obese with morbid obesity which is the main cause for

Paraumbilical Hernia and comes under the policy exclusion F vi. The Forum has noted that the most common

causes for Umbilical hernia in adults are Chronic health conditions that raise abdominal pressure, Carrying

excessive belly fluid (ascites), chronic cough, difficulty urinating due to an enlarged prostate, prolonged

constipation, repetitive omitting, obesity, straining such as during child birth or weight lifting. The forum has

observed that obesity may be one of the contributory factor for Paraumbilical Hernia and other factors may

not be ruled out for causing Paraumbilical Hernia. In fact the obesity has a higher chance of developing the

health problems of High Blood glucose or diabetes, High Blood Pressure(HTN), High Blood cholesterol and

triglycerides, Heart attacks, heart failure and stroke, Bone and joint problems, sleep apnea, gallstone and liver

problems etc., Hence if we apply the obesity and its complications for admissibility of claims under the policy

no claim is payable under the policy.

On careful examination of the policy exclusion F vi. the forum has observed that the policy excludes OBESITY

TREATMENT AND ITS COMPLICATIONS which may be inferred as Obesity treatment and the complications of

obesity treatment i.e. after effects of obesity treatment. The Forum accepts that the policy is the evidence of

contract and subject to terms conditions and exclusions. However while interpreting the policy exclusions the

RI should not deviate from the main purpose of the contract i.e. to cater medical expenses incurred by the

insured.

Hence the forum felt that the RI has misinterpreted the policy exclusion and rejected the claim on assumptions

and presumptions.

In view of the above discussions, the forum finds that the repudiation of claim by the Respondent Insurer is

not in order and directs the RI to settle the claim in accordance with the terms and conditions of the policy.

Accordingly the complainant is ALLOWED.

A W A R D

Taking into account the facts & circumstances of the case and the submissions made by both the parties during

the course of the OnLine Hearing and the information/documents placed on record, the Respondent Insurer is

directed to settle the claim under the existing policy terms and conditions.The complaint is ALLOWED.

22) The attention of the Insurer is hereby invited to the following provisions of Insurance Ombudsman Rules,

2017:

d) According to Rule 17(6), the insurer shall comply with the award within 30 days of the receipt of the award and intimate compliance to the same to the Ombudsman.

e) According to Rule 17(7), the complainant shall be entitled to such interest at a rate per annum as specified in the regulations, framed under the Insurance Regulatory & Development Authority of India Act from the date the claim ought to have been settled under the Regulations till the date of payment of the amount awarded by the Ombudsman.

f) According to Rule 17 (8), the award of Insurance Ombudsman shall be binding on the Insurers.

Dated at Hyderabad on the 26th day of AUGUST , 2021.

( SURESH CHANDRA PANDA )

OMBUDSMAN

FOR THE STATES OF A.P.,

TELANGANA AND YANAM CITY

PROCEEDINGS BEFORETHE INSURANCE OMBUDSMAN, STATE OF KARNATAKA (UNDER RULE NO: 17 OF THE INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN – POONAM BODRA In the matter of MR. ABHISHEK BHEEM RAO Vs THE NEW INDIA ASSURANCE CO. LTD.

Complaint No: BNG-H-049-2021-0814

Award No.: IO/(BNG)/A/HI/0041/2021-22

1 Name & Address of the Complainant Mr. Abhishek Bheem Rao #3/1, 1st Cross, New Guddadahalli, Mysore Road, Near Osteen Kids School, Belgaum, Karnataka - 560026 Mobile no: 9972733997 Email ID: [email protected]

2 Policy Number Type of Policy Duration of Policy/ Policy Period

12020034190400000028 Group Mediclaim 31.03.2020 to 30.03.2021

3 Name of the Policyholder/Proposer Name of the Insured

Conversant SDCMS Mr. Abhishek Bheem Rao

4 Name of the Insurer The New India Assurance Company Limited

5 Date of repudiation NA

6 Reason for repudiation NA

7 Date of receipt of the Annexure VI A 29.03.2021

8 Nature of complaint Short Settlement of health claim (COVID-19)

9 Amount of claim Rs,1,71,282/-

10 Date of Partial Settlement 18.09.2020

11 Amounts of relief sought Rs.84,779/-

12 Complaint registered under Rule no. 13 (1) (b) of Insurance Ombudsman Rules, 2017

13 Date of hearing through Online VC 23.07.2021

14 Representation at the hearing

a) For the Complainant Self

b) For the Respondent Insurer Mrs. Rajalakshmi K (Asst. Manager)

15 Complaint how disposed Allowed

16 Date of Award/Order 03.08.2021

17. Brief Facts of the Case: The complaint emanated from short settlement of health claims by Respondent insurer (hereafter referred to as RI). The Complainant represented to Grievance Redressal Officer (GRO) of RI for reconsideration of his claim. However his plea was not considered favourably. Hence the Complainant approached this Forum for resolution of his grievance.

18. Cause of Complaint: a) Complainant’s arguments: The Complainant (Insured Person – IP) submitted that he was covered under group mediclaim policy with RI vide policy no. 12020034190400000028 for the period 31.03.2020 to 30.03.2021. The IP was diagnosed with COVID-19 and admitted at P. M. Santhosha Hospital wherein he had undergone conservative treatment for the same. The reimbursement claim for the medical expenses incurred towards hospitalisations was settled by the RI for Rs.84,779/- against the claimed amount of Rs.1,71,282/-. The IP represented with GRO of RI for settlement the balance amount. Aggrieved of no favourable outcome from the RI, IP approached this forum for the resolution of his grievance.

b) Respondent Insurer’s Arguments: The RI in their Self Contained Note (SCN) dated 13.07.2021 whilst admitting insurance coverage and settlement of claim, submitted that the reimbursement claim was settled as per GIC council rates for Covid treatment as per GIC council circular dated 20.06.2020. The total claim including pre and post hospitalisation was settled as:

For 7 days room rent at 7200 *7 = Rs.50,400/- Medicines = Rs. 6,328/- Consultation charges 1250*7 = Rs. 8,750/- Lab test = Rs. 6,000/- Total comes as ...........................…. Rs.71,478/-

However they settled the claim for Rs.86,503/- which is in excess of the total amount.

In view of their submissions, the RI prayed for passing an appropriate order.

19. Reason for Registration of complaint: The complaint falls within the scope of the Insurance Ombudsman Rules, 2017.

20. The following documents were placed for perusal: Complaint along with enclosures, Respondent Insurer’s SCN along with enclosures and Consent of the Complainant in Annexure VIA & and Respondent Insurer in VII A

21. Result of personal hearing with both the parties (Observations & Conclusions): The dispute is whether settlement of health claims under the policy is in order or not.

Personal hearing by the way of online Video-conferencing through GoTo Meet was conducted in the said case. Complainant and Representatives of RI joined using online VC and presented their case. Confirmation from all the participants about the clarity of audio and video was taken to which the participants responded positively. Both the parties reiterated her earlier submissions.

Forum has perused the documentary evidence available on record and the submissions made by both the parties during the personal hearing.

Forum notes that IP was diagnosed with COVID-19 and he was hospitalised at P. M. Santhosha Hospital, Bangalore from 25.07.2020 to 01.08.2020. The IP filed a reimbursement claim of Rs.1,71,282/- for the medical expenses incurred by him. The claim was settled by RI for Rs.86,503/- considering tariff rate of GIC guidelines for the settlement of the Covid claim.

Forum notes that as per IRDAI circular reference no IRDAI/HLT/REG/CIR/011/01/2021 dt 13.01.2021 regarding Communication on settlement of health insurance claims against General Insurance Council’s instructions dated 20th June 2020 on “Reference Rates for COVID-19”, Insurance Companies were directed to ensure that the “Reimbursement claims” under a health insurance policy shall be settled as per the terms and conditions of the respective policy contract. Hence, the insurers shall honor all the health insurance claims as per the terms and conditions of the policy contract.

The same was reiterated in IRDAI circular reference no IRDAI/HLT/MISC/CIR/102/04/2021 dt 23.04.2021. Hence the contention of RI that the claim settlement as per of GIC is untenable. Accordingly during the course of personal hearing the RI was asked to submit the eligible claim amount as per the policy terms and conditions and the RI vide their email dated 30.07.2021 submitted the payable amount as follows:

Charge Type Bill Amount

Payable Amount

Non Pay Amount

Non Payable Reason

Hospital Charges 112000 112000 0

Investigation & Lab Charges 6650 6650 0

Miscellaneous Charges 850 300 550 Registration, Administration

Consultant Charges 16120 6642 9478 9478/-Discount

Pharmacy & Medicine Charges 10139 10139 0

Procedure charges 35000 25200 9800 PPE kit paid at 3600 per day

Total 180759 160931 19828

Forum observes that the RI has already settled an amount of Rs.86,503/- vide claim settlement letter dated 18.09.2020, the balance amount of 74,428/- (i.e. 160931-86503) is to be paid to the IP. The complaint is allowed.

A W A R D

Taking account of the facts and circumstances of the case and the submissions made by both the parties and documents submitted during the course of the Personal Hearing, the Respondent Insurer is directed to settle the claim for balance amount of Rs.74,428/- without interest.

The Complaint is Allowed.

Dated at Bangalore on the 3rd day of August, 2021.

(POONAM BODRA) INSURANCE OMBUDSMAN

ADDITIONAL CHARGE FOR THE STATE OF KARNATAKA

PROCEEDINGS BEFORETHE INSURANCE OMBUDSMAN, STATE OF KARNATAKA (UNDER RULE NO: 17 OF THE INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN – POONAM BODRA In the matter of MR. SANJAY S KANADE Vs THE NEW INDIA ASSURANCE CO. LTD.

Complaint No: BNG-H-049-2021-0798

Award No.: IO/(BNG)/A/HI/0050/2021-22

1 Name & Address of the Complainant Mr. Sanjay S Kanade

H # 3406, Samadev Galli

Belgaum, Karnataka - 590001

Mobile no: 9480432360

Email ID: [email protected]

2 Policy Number

Type of Policy

Duration of Policy/ Policy Period

12070034200400000007

Group Mediclaim

01.04.2020 to 31.03.2021

3 Name of the Policyholder/Proposer LIC of India

Name of the Insured Mr. Sanjay S Kanade, Mrs. Samruddhi

4 Name of the Insurer The New India Assurance Company Limited

5 Date of repudiation NA

6 Reason for repudiation NA

7 Date of receipt of the Annexure VI A 26.03.2021

8 Nature of complaint Short Settlement of health claim (COVID-19)

9 Amount of claims Claim # 102207596 Claim # 102207719

Rs.7,05,279/- Rs.87,226/-

10 Dates of Partial Settlement 14.12.2020, 16.01.2021 16.12.2020, 19.01.2021

11 Amounts of relief sought Rs.60,241/- Rs.23,215/-

12 Complaint registered under Rule no. 13 (1) (b) of Insurance Ombudsman Rules, 2017

13 Date of hearing through Online VC 23.07.2021


a) For the Complainant Self

b) For the Respondent Insurer Mrs. Rajalakshmi K (Asst. Manager)

15 Complaint how disposed Disallowed


17. Brief Facts of the Case: The complaint emanated from short settlement of health claims by the Respondent insurer (hereafter referred to as RI). The Complainant represented to Grievance Redressal Officer (GRO) of RI for reconsideration of his claims. However his plea was not considered favourably. Hence the Complainant approached this Forum for resolution of his grievance.

18. Cause of Complaint: a) Complainant’s arguments: The Complainant submitted that he along with his wife Mrs. Samruddhi was covered under group mediclaim insurance policy with RI vide policy no. 12070034200400000007 for the period 01.04.2020 to 31.03.2021. Both of them were diagnosed with COVID-19 and they were admitted at Shree Ortho & Trauma Centre, Belagavi wherein they had undergone conservative treatment for the same. The Complainant filed the claims (self and spouse) for the medical expenses incurred towards their hospitalisations. The RI approved the claims for Rs.3,67,225/- and Rs.34,726/- against the claimed amounts of Rs.7,05,279/- and Rs.87,226/- respectively. The Complainant represented with GRO of RI for settlement the balance amounts wherein the RI further settled for Rs.2,77,813/- and Rs.29,735/- leaving the shortage of Rs.60,241/- and Rs.23,215/- in his respective claims. Aggrieved of the short settlement the Complainant approached this forum for the resolution of his grievances.

b) Respondent Insurer’s Arguments: The RI submitted in their Self Contained Note (SCN) vide mail dated 27.04.2021 that a group health policy was issued to LIC Employees for the period from 01.04.2020 to 31.03.2021 wherein the Complainant and his wife were included in the list of insured persons with a floater sum insured of Rs.50,00,000/-. Both of them were

hospitalised for COVID-19, at Shree Ortho & Trauma Centre, Belagavi and they were admitted in general category and not in ICU. Thus the eligible limit for the room rent per day is Rs.4,000/- but as a Covid case the claim was settled as per Rs.7,500/- room rent per day and the proportionate deductions were applied. As the claimant is already paid extra amount over and above amount payable as per terms of the policy, no further amount is payable in the claims.

In view of their submissions, the RI prayed for passing an appropriate order.

19. Reason for Registration of complaint: The complaint falls within the scope of the Insurance Ombudsman Rules, 2017.

20. The following documents were placed for perusal: a) Complaint along with enclosures, b) Respondent Insurer’s SCN along with enclosures

and c) Consent of the Complainant in Annexure VIA &

and Respondent Insurer in VII A

21. Result of personal hearing with both the parties (Observations & Conclusions): Personal hearing by the way of online Video-conferencing through GoTo Meet was conducted in the said case. The Complainant and Representative of RI joined using online VC and presented their case. Confirmation from all the participants about the clarity of audio and video was taken to which the participants responded positively. Both the parties reiterated their earlier submissions. The Complainant strongly argued that the claims should be settled as per terms and conditions of the policy. The RI strongly contended that considering the GIC circular they have paid more than the eligible amount as per policy terms and conditions.

The Forum directed the RI to furnish the calculation as per policy terms and conditions which they submitted after the hearing vide their email dated 05.08.2021.

Forum notes that the complainant filed a single complaint mentioning two claim numbers towards self and spouse. Both the claims were considered under single complaint. The Forum has perused the documentary evidence available on records and the submissions made by both the parties during the personal hearing pertaining to both the Claim Nos.

The dispute is whether partial settlement of health claims under the policy is in order or not.

Forum notes that Mr. Sanjay S Kanade and his wife Mrs. Samruddhi were diagnosed with COVID-19 and they were hospitalised at Shree Ortho & Trauma Centre, Belagavi on 20.09.2021. Mr. Sanjay S Kanade was discharged on 15.10.2020 whereas Mrs. Samruddhi was discharged on 23.09.2020. The Complainant filed reimbursement claims for self and spouse of Rs.7,05,279/- and Rs.87,226/- respectively. The RI has initially processed the claims as per GIC circular dt.20.06.2020 considering the room rent tariff of Rs.7,500/- per day and settled Rs.3,67,225/- vide claim no. 1017932176 and Rs.29,375/- vide claim no. 102207719 respectively for both the claims. After the representation from the complainant they reprocessed the claim and paid an additional amount of Rs.2,77,813/- and Rs.34,726/- under new claim nos. 102207596 and 101885268 respectively. Hence the total amount paid under both the claims works out to Rs.6,45,038/- and Rs.64,101/- considering room rent tariff of Rs.7500/- per day.

The Forum finds that as per the policy terms and conditions the complainant is eligible for room rent tariff of Rs.4000/-per day. Accordingly the claims work out as under:

Claim of Mr. Sanjay S Kanade

Break-up as per policy conditions (room rent Rs.4000/-per day)

Charge Type Bill Payable Non Pay Non Payable Reason

Amount Amount Amount

Room

Charges 221000 104000 117000

117000/-Excess of Room Rent as per

policy Sub limit (Rs.4000/-per day)

Investigation

& Lab

Charges 29050 29050

Miscellaneo

us Charges 13500 0 13500

500/- Registration charges,

13000/- Food charges.

Consultant

Charges 182000 85647 96353

96353/- Excess of proportionate

deductions as per eligible room category

Pharmacy

Charges 166529 147126 19403

703/- Respirometer

18700/- Hospital discount

Hospital

other charges 93200 43859 49341

Excess of proportionate deductions as per

the eligible room category

Total 705279 409682 295597

Claim of Mrs. Samruddhi

Break-up as per policy conditions (room rent Rs.4000/-per day)

Charge Type Bill

Amount

Payable

Amount

Non Pay

Amount

Non Payable Reason

Room Charges 30000 12000 18000 18000/- Excess of Room Rent

Miscellaneous

Charges 8000 0 8000

6500/-Service charges,

1500/-Food and water

Consultant

Charges

33000 13200 19800

19800/- Consultation/doctor charges-

Proportionate deduction due to higher

room rent occupancy

Hospital

Charges

4000 1600 2400

Excess of Monitoring and Oxygen chares-

Proportionate deduction due to higher

room rent occupancy

Pre and post

hospitalisation

Charges 12226 12226

Total 87226 39026 48200

Considering the above calculations the Forum concludes that the RI has settled the claims in excess of Rs.2,35,356/- and Rs.25,075/- towards both the claims respectively. Thus a total amount of Rs.2,60,431/- is paid in excess to the complainant.

In view of the above the Forum relies on the Supreme Court’s judgment held in case of Oriental Insurance Co. Ltd vs Sony Cheriyan on 19 August, 1999, that

“The insurance policy between the insurer and the insured represents a contract between the parties. Since the insurer undertakes to compensate the loss suffered by the insured on account of risks covered by the insurance policy, the terms of the agreement have to be strictly construed to determine the extent of liability of the insurer. The insured cannot claim anything more than what is covered by the insurance policy.”

Hence the Forum concludes that the complainant is not entitled for the excess claim settlement beyond the eligible amount as per terms and conditions of policy. Accordingly the Forum directs the RI to recover excess claims paid of Rs.2,35,356/- and Rs.25,075/- under both the claim nos. (Totalling to Rs.2,60,431/-). The complainant is directed to pay the excess amount of Rs.2,35,356/- and Rs.25,075/- under both the claim nos. to the RI for which he is not entitled as per terms and conditions of policy. The complaint is disallowed.

A W A R D

Taking into account of the facts and circumstances of the case and the submissions made by

both the parties and documents submitted during the course of the Personal Hearing, the

Respondent Insurer is directed to recover the excess amount i.e. Rs.2,60,431/- paid to the

complainant under both the claims and the Complainant is directed to pay the excess amount

to the Respondent Insurer accordingly.

The Complaint is Disallowed.

Dated at Bangalore on the 10th day of August, 2021.

(POONAM BODRA) INSURANCE OMBUDSMAN

ADDITIONAL CHARGE FOR THE STATE OF KARNATAKA

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF ODISHA, BHUBANESWAR

(UNDER RULE NO: 16(1)/17 OF THE INSURANCE OMBUDSMAN RULES, 2017) OMBUDSMAN – Shri Suresh Chandra Panda

CASE OF Mr. J.J.M.S.S. Karan Bharatiya Vrs. TATA AIG General Insurance Co. Ltd

COMPLAINT REF: NO: BHU-H-047-2122-0040 AWARD NO: IO/BHU/A/HI/ /2021-22

1. Name & Address of the Complainant

Mr. J.J.M.S.S. Karan Bharatiya Shivasakti Nagar, Lane-9, Puri Canal Road, Bhubaneswar, Dist: Kurda-754101. Mob-9937174459

2 Policy No: Type of Policy Duration of policy/Policy period

0237932525/001218. Group Medicare Policy 25/02/2020 to 24/02/2021 (inception 22/02/2019) Date of admission 01/02/2021 D.O.D 05/02/2021

3. Name of the insured Name of the policyholder

Mr. J.J.M.S.S. Karan Bharatiya Mr. J.J.M.S.S. Karan Bharatiya

4. Name of the insurer TATA AIG General Insurance Co. Ltd

5. Date of Repudiation 19/03/2021 Fraudulent Claim 6. Reason for repudiation

7. Dt of receipt of the Complaint

26/04/2021

8. Nature of complaint Requested to advice the Insurer to settle the claim

9. Amount of Claim Rs.74,500 + 1,00,000/- for mental harassment

10. Date of Partial Settlement Not applicable

11. Amount of relief sought Rs. 74,500 + 1,00,000/- for mental harassment

12. Complaint registered under Rule no: of IO rules

13(1)b

13. Date of hearing/place 20/08/2021, Bhubaneswar


a) For the Complainant Self through phone

b) For the insurer Dr. Dhiraj Mhatre, Executive through VC

15 Complaint how disposed U/R 17 of the Insurance Ombudsman Rules, 2017

16 Date of Award/Order 20/08/2021

17. a. Brief Facts of the Case/Cause of Complaint: - The Complainant Mr. J.J.M.S.S.S Karan Bharatiya is covered under policy No. 0237932525/001218 for the period from 25/02/2020 to 24/02/2021 having sum insured of Rs.5,00,000/-. He was hospitalised in Rudra Hospital, N.H. 5 Bhanpur, Gopalpur, Cuttack on 01/02/2021 due to viral fever, loose motion, vomiting, sepsis and discharged on 05/02/2021. He lodged a claim for reimbursement of hospital expenses which was rejected by the insurer on the ground, the lodged claim is a fraudulent claim. Being aggrieved the complainant made an appeal before this forum for redressal. b. The insurer in their self-contained note confirmed issuance of the above policy and stated that the complainant was admitted in Rudra Hospital, Gopalpur, Cuttack for the period 01 February 2021 to 05 February 2021. It was observed that the complainant was diagnosed with Viral Fever, Loose Motions, Vomiting, Sepsis. Estimate Claim Amount - INR 74941/- On receipt of the claim on 11 February 2021 [Claim No – 2021021100113] they had done a thorough investigation and noticed various irregularities; hence claim was denied under fraud vide letter dated 19 March 2021.They highlighted the major discrepancies/irregularities in this case for the perusal of the forum:

Below mentioned spelling errors found;

Source Error Actual Real Spelling

Discharge Card, Claim form Sepesies Sepsis

Discharge Card Disorented Disoriented

Discharge Card Louse motions Loose motions

Hospital Bill Himoglobin Hemoglobin

Dishcarge Card Controlly Controlling

It is highly unlikely that a qualified Doctor would do such spelling errors. In final diagnosis “loose motions & vomiting” is mentioned. Generally, these terms are never used in final Diagnosis in Discharge card. All physicians use “Gastroenteritis/Dysentery” in final diagnosis. For Sepsis & Kidney Failure patient, following investigations are not done; Blood/Urine Culture & Sensitivity C Reactive Protein [CRP] Chest X Ray ECG Stool Routine Abdomen Sonography Signature of Consultant Pathologist & Lab Technician is missing from diagnostic reports. Hemoglobin values of 12.4 is same on 01, 02, 03 February 2021. It is highly unlikely that Hemoglobin value would remain same for consecutive 3 days in Sepsis patient. Generally Hemoglobin value changes due to multiple factor like infection/Sepsis, Hydration, Food Intake etc. Patient was drowsy on 01, 02, 03 February 2021. Below mentioned things are missing; a. CNS [Central Nervous System] Examination in detail like Tone, Power, Reflexes. b. CT/MRI Brain c. EEG d. Reference to Consultant Neurologist A cursory look at the Indoor Case papers show that they were written by one person at a stretch. When a person is admitted for 5 days it is unlikely that the treating doctor/nurse was on duty 24 hours a day during the course of admission. Generally in Indoor Case papers, before writing daily notes all Physicians write,”S/B Dr.XYZ”. but such comments are missing. Also, generally Physicians write their time of visit to patient, however time of visit is also missing from Indoor Case papers. In hospital indoor case papers [especially in admission notes] other systemic examination like R.S. [Respiratory system] C.V.S. [Cardio Vascular System] C.N.S [Central Nervous System] etc is missing. Since Kidney Failure patient was admitted for 5 days, it was expected that treating Doctor would do thorough systemic examination. Lab report values not noted in indoor case papers. After viewing Lab reports, generally Physicians note those values in their notes in indoor case papers so that Doctor who sees patient thereafter observes that earlier Doctor has taken cognizance of those lab tests results. On admission, Serum potassium levels were lower than normal – 3.0 [Normal Range – 3.5 to 5.5 mmol/L, still Potassium supplement like injectable/syrup format was not given nor “Electrolyte Imbalance” mentioned in final Diagnosis in Discharge card. Even Serum Sodium level was lower than normal – 128.4 [Normal Range – 135 to 155 mmol/L.

On admission, Serum Creatinine levels were higher than normal – 2.0 [Normal Range – 0.5 to 1.5 mg/dl, still “Acute Renal Failure” was not mentioned in final Diagnosis in Discharge card. Insured was not catheterized. Catheterization orders not found in indoor case papers nor purchase of Catheter, Urobag, Urometer is seen in chemist bills. Thus, he was passing urine by himself. As per Input/ Output chart, patient was seen passing 600, 700, 800, 1000 ml urine at one time. The typical human bladder will hold between 300 - 500 ml before the urge to empty occurs, but can hold considerably more. Hence passage of urine > 600 ml at one time is not understood. Patient was admitted for total 5 days. In 5 days, stools passed or not is never mentioned in indoor case papers. Surprisingly Prepost hospitalization claim documents not submitted. Generally patient with so many complications visits Doctor after discharge for follow-up. In admission case paper, as a routine, treating Physician has mentioned battery of tests to be done after admission. In those tests, TLC [Total Leucocyte Count] was also advised to assess level of infection [White Blood Cells] in the body. Surprisingly on the same paper, Injection Meropenum 1 gram was also written. Total 13 Injections Merofit purchase shown for INR 31,200/- Generally Meropenum is given to seriously ill complicated ICU patient battling life threatening infections. In this case insured was in private room. In claim form, in question No – 4 towards “Are you presently covered with any other Mediclaim/Health Insurance Policy”, insured has mentioned “No”, whereas he is holding Star Health Policy also. In question No -8 in investigator’s questionnaire also insured has replied in negative. In question No – 10 of investigator’s questionnaire, insured has written that complaints started since 31 January 2021 ie just 1 day before admission. However as per admission case paper & in question No - 3 in investigator’s questionnaire [treating Doctor section], complaints started for 3 days. Food orders are missing in indoor case papers, like NBM [Nill by Mouth], Liquid diet, soft diet etc. In a Hospitalisation case there are dietary restrictions placed on the patient. However, food orders like NBM [Nil by Mouth], Liquid diet, soft diet etc are missing in Indoor case papers. On admission Lipid profile was done in this non cardiac patient, which showed normal Values. Hospital billed INR 500/- towards same in bill No – B4578 dated 01 February 2021. Still again Hospital has charged INR 500/- on 02 February 2021 in bill No – B4580. On admission RBS [Random Blood Sugar] was done in this non-Diabetic patient, which showed normal Value [129mg/dl]. Hospital billed INR 50/- towards same in bill No –B4578 dated 01 February 2021. Still again Hospital has charged INR 50/- on 02 February 2021 in bill No – B4580. Again, Hospital has charged INR 50/- on 03 February 2021 in bill No – B4597. Below abuse noted in chemist bills;

1-Feb 2-Feb 3-Feb 4-Feb 5-Feb Total

NS 500 ml

3 3 2 2 2 12

RL 1 1 2 3 7

DNS 2 2

21 IV bottles for 5 days admission seems to be abuse. In chemist bills, total 15 Injection Infupar [Paracetamol] purchase seen for INR 7485/- still from 01 February 2021 to 04 February 2021 continuous fever [>100-degree Fahrenheit] noted. Generally, after giving one single Paracetamol injection, temperature comes to normal for at least 4-5 hours. Another Paracetamol injection by brand name Febrinil / Aeknil also comes for 10-20 Rupees per injection & it also reduces fever like injection Infupar does. Inspite of daily fever till 04 February 2021, how discharge was given 05 February 2021 is not understood. Generally, Physician makes sure that patient doesn’t

have fever for last 48 hours, then only he advises discharge & ask patient to come with certain lab tests after few days during follow up visit.


Inj. Infupal Quantity

3 3 3 3 3 15

Cost 1497 1497 1497 1497 1497 7485

In chemist bills,total 5 Injection Xetox 600 mg [Glutathione] purchase seen for INR 6495/-. In this patient as per lab reports, his Liver function was within normal limits. Hence indication of administration of Injection Xetox is not understood. Medical Literature of Injection Xetox is annexed with SCN


Inj. Xetox 600 mg Quantity 1 1 1 1 1 5

1299 1299 1299 1299 1299 6495

Room No, Bed No, Dr’s name, Patient’s name is missing from Vital Chart & Input/Output Chart. Generally, on each chart, hospitals write these basic details to avoid mixing of case sheets with another patient in order to prevent further calamity. Relative/friend’s signature is missing from admission consent form. In admission form, generally any hospital takes relative’s name/contact Number/Signature. It is quite surprising that not a single relative accompanied to hospital with disoriented patient with low urine output. Insured was admitted during Covid pandemic & was having classical Covid symptoms like fever, vomiting, loose motions, still surprisingly Covid Swab test was not done. On 02 February 2021, Temparature-104-degree Fahrenheit & patient was in Sepsis. Surprisingly, Pulse rate-84/min [Normal Range: 60 to 100/Minute]. Generally, Fever causes Tachycardia [increase Heart Rate] & Sepsis causes reflex Tachycardia. With this kind of High-grade fever & Sepsis, Pulse rate should have been > 100/minute. As per Discharge Card & Admission Form, time of Admission is 07.22 PM, but as per Medication chart, drugs have been administered since 11 am in the morning. As per Vital chart, Pulse/BP recorded from 11 am in the morning. As per Input/Output chart, 200 ml urine was passed on 11 am in the morning. Even in question No – 14 of investigator’s questionnaire, insured has written TOA-11.30 am. Also, there was discrepancy regarding Discharge date & time as below;

Source Date of Discharge Time of Discharge

Discharge Card 5-Feb-21 12.54 P.M. 9Afternoon)

Insured Declaration 5-Feb-21 4.30 P.M. (Evening)

Hospital Bill 6-Feb-21 09.08 AM (Morning)

Also there was discrepancy in Payment Receipts as below ; Payment Receipt No MR2021-194 dated 05/02/2021 at 12:55 PM Payment Receipt No MR2021-194 dated 06/02/2021 at 09:05 PM Same receipt Number / Same amount but Issue date/Time is Different. On 01 February 2021, three times Blood Pressure measured during entire day [11 am, 2 pm, 6 pm, 10 pm]. Surprisingly every time same Blood Pressure recorded – 110/70 mm of Hg..On 03 February 2021, four times temperature taken during entire day [6 am, 2 pm, 6 pm, 10 pm]. Surprisingly every time same temperature recorded – 102 Degree Fahrenheit.

Difference noted in symptoms at various places, as below; Discharge Card ICP Insured’s statement Treating Dr’s Statement

Discharge Card ICP Insured’s statement Treating Dr’s Statement

Disoriented

Fever Fever Fever Fever

Abdominal pain

Vomiting Vomiting Vomiting Vomiting

Loose motion Loose motion Loose motion Loose motion

Less Urination Less Urination Less urination

During investigators’ visit to hospital, authorities has not provided Drug Purchase invoice / stock register, Drug License, Hospital tariff, Pathologist registration certificate. From the above observations it is clear that the claim is fabricated and fraud & ultimately claim was denied. Claims of the complainant have been processed as per the terms and conditions of the policy. The complaint is devoid of any merit and hence the same should be dismissed 18. a. Complainant’s Argument; -He has submitted all the required documents but the Insurer rejected his claim without any proper reason. b. Insurer’s Argument: it is clear that the claim is fabricated and fraud & ultimately claim was denied. The complaint is devoid of any merit and hence the same should be dismissed 19. Reason for Registration of Complaint: Scope of the Insurance Ombudsman Rules, 2017 20. The following documents are placed in the file.

a. Policy copy and clauses b. Photo copy of medical report and bills.

21. Result of hearing with both parties (Observations & Conclusion): - This Forum has carefully gone through all the documents relating the complaint and heard both the parties. The insurer stated the facts and appealed for dismissing the case on the ground of various irregularities in medical documents, misrepresentation of facts in proposal form, unreasonable advice of injections/medicines, treatment without covid test and other similar reasons. The complainant stated that his hospitalization was genuine, but the insurer rejected the claim. Dated at Bhubaneswar on the 20th day of August, 2021 INSURANCE OMBUDSMAN

FOR THE STATE OF ODISHA

AWARD

Taking into account the facts and circumstances of the case and submissions made by

both the parties during the course of hearing and examination of documents, the

Forum finds inconsistent medical reports, unreasonable medical records, irregularities

in treatment records. Therefore, the complainant is not entitled for the present claim.

Accordingly, the complaint stands dismissed.

PROCEEDINGS OF THE INSURANCE OMBUDSMAN, CHANDIGARH (Under Rule 13 r/w 17 of The Insurance Ombudsman Rules, 2017)

Insurance Ombudsman: Shri Sudhir Krishna

Case of Kailash Chander V/S The Oriental Insurance Co. Ltd.

Complaint Ref. No.: CHD-H-050-2021-0700

1. Name & Address of the Complainant Shri. Kailash Chander

1424, Street No. 1, Nai Basti, Bathinda, Punjab-151001

Mobile No.-7814809138

2. Policy No:

Type of Policy

Duration of policy/Policy period

233200/48/2019/629

Group Health Policy

23-05-2018 To 22-05-2019


Name of the policyholder

Kailash Chander

Kailash Chander

4. Name of the insurer The Oriental Insurance Co. Ltd.

5. Date of Repudiation 09.10.2018,17.01.2019 & 15.02.2019

6. Reason for repudiation Claims not covered in day care treatment

7. Date of receipt of the Complaint 05-03-2021

8. Nature of complaint Denial of three mediclaims

9. Amount of Claim Rs.1,18,400/-

10. Date of Partial Settlement N.A

11. Amount of relief sought Rs.2,00,000/-

12. Complaint registered under Rule no:

Insurance Ombudsman Rules, 2017

Rule 13 (1)(b) – any partial or total repudiation of claims

by an insurer

13. Date of hearing/place 06.08.2021/ Online hearing


For the Complainant Shri Kailash Chander, the complainant

For the insurer Shri Vikas Kataria, Dy. Manager Bhatinda

15 Complaint how disposed Award under Rule 17


17. Brief Facts of the Case: Shri Kailash Chander (hereinafter, the complainant) has filed this complaint against The Oriental

Insurance Co. Ltd. (hereinafter, the insurers) alleging incorrect rejection of his three claims.


a) Complainant’s argument: His daughter developed disease of RRMS on 20.02.2018 and claim of Rs.44260/- was paid by

the insurer vide their letter No. RTI/230000/2018/108 dated 20.02.2018. But subsequent three claims were denied on the

ground that day care treatment is not covered. He had sent treatment papers for reimbursement on 18.08.2018 for

Rs.11600/- but TPA closed the file as No Claim due to non-consideration of day care treatment. On 29.11.2018 treatment

papers for Rs.80600/-were again sent. The complainant again sent treatment papers on 17.01.2019 for the period

04.08.2018 to 06.01.2019 along with the details of the treatment expenses but insurer denied his claims for Rs.1,18,400/-

only. In support of Day Care Treatment he submitted Delhi Heart Institute certificate dated 17.10.2018 certifying that during

admission the patient is observed for any untoward reaction as antipyretic and antihistamine given. The complainant further

stated that he represented to TPA vide reminder on 15.01.2019 for settlement of claim and to insurer on 23.03.2019 and

25.05.2019 that claims may please be paid but they denied these claims vide letters no nil dated 09.10.2018, 17.01.2019

and 15.02.2019.

b) Insurers’ argument: TPA has rejected three claims of Rs.11600/-, Rs.80,600/- and Rs.37800/- with remarks “Case of RRMS

(Relapsing Remitting Multiple Sclerosis) managed conservatively. There was less than 24 hrs of admission. Neither

Chemotherapy was given and nor the given treatment falls in Day care list. Minimum 24 Hrs. hospitalization is required as

per policy terms and conditions. So the claim is recommended to be non-payable as per clause 3.18 as expenses on

hospitalization are admissible only if hospitalization is for minimum period of 24 hours. Insurers stated that Patient was

admitted as a case of RRMS and treated with injection Intra muscular (INF), which can be given on OPD basis and does not

require hospitalization. This treatment does not require 24 hours hospitalization nor listed under day care list. Hence claims

remain non-payable.

19. Reason for Registration of Complaint: Incorrect denial of claims.


a) Complaint to the Company b) Copy of Policy Document

c) Annexure VI-A d) Reply of the Insurance Company

21. Result of Personal hearing with both parties (Observations & Conclusion):


As has been amply explained in Para 18b above, the treatment administered to the insured would not come under the

category of hospitalization and is also not covered in the list of Admissible Daycare Procedures vide Appendix-I of the Policy.

Therefore, the Insurers were justified in repudiating the claim. Pursuantly, the complaint shall deserve to be rejected.

Award

The complaint is rejected.

(Sudhir Krishna)

Insurance Ombudsman

August 06, 2021

PROCEEDINGS OF THE INSURANCE OMBUDSMAN, CHANDIGARH

(Under Rule 13 r/w 16 of The Insurance Ombudsman Rules, 2017)


Case of Mahabir Parshad Sharma v/s The United India Insurance Co. Ltd.

Complaint Ref. No.: CHD-H-051-2021-0747

1. Name & Address of the Complainant Shri Mahabir Parshad Sharma

H. No. 191-P, Sector 20, Huda, Sirsa, Haryana- 125055

Mobile No.- 9050248191

2. Policy No:

Type of Policy


5001002819P112263948

Group Mediclaim Policy

01-11-2019 To 31-10-2020



Mahabir P Sharma & Shakuntla Sharma

Indian Bank’s Association A/c PNB

4. Name of the insurer The United India Insurance Co. Ltd.

5. Date of Repudiation 04.12.2020

6. Reason for repudiation Repudiated as per clause 2.19 & 3.3


8. Nature of complaint Repudiation of claims

9. Amount of Claim Rs. 294416/-


11. Amount of relief sought Rs. 294416/-

12. Complaint registered under Rule no:

Insurance Ombudsman Rules, 2017

Rule 13 (1)(b) – any partial or total repudiation of claim

by an insurer



For the Complainant Shri Mahabir Parshad Sharma, the complainant

For the insurer Smt. Pamela Pinto, Deputy Manager (LCD), Mumbai

15 Complaint how disposed Recommendation under Rule 16


17. Brief Facts of the Case: Shri Mahabir Parshad Sharma (hereinafter, the Complainant) has filed this complaint against the

United India Insurance Co. Ltd. (hereinafter, the Insurers) for non-settlement of health claims.


a) Complainants argument: He retired from PNB on 30.06.2019. His wife Smt. Shakuntla Sharma is suffering from Metastatic

Carcinoma-breast and is under treatment since July 2016. Since then the chemotherapy (Trastuzumab) is being given at an

interval of every 21 days w.e.f 18.07.2016 and every month w.e.f. 11.10.2019 in day care. TPA/UIIC has sanctioned and paid

all the claims of above treatments till 30.10.2019. They started rejection of claims from November 2019, i.e. for the policy

period 01.11.2019 to 31.10.2020 although there was no change in the terms and conditions of the policy from the previous

year policy. Eleven claims amounting to Rs.294416/- were rejected, while one claim of Rs. 29610/- (DOA – 12.09.20) was paid

on 15.12.2020. Rejected claims are of Rs.28378/-(Date of admission-08.11.19), 28806/- (DOA-09.12.2019), 28918/- (DOA-

08.01.2020), 44667/- (DOA-08.02.2020), 29317/- (DOA-11.03.2020), 28639/- (DOA-10.04.2020), 29121/- (DOA-11.05.2020),

34930/- (DOA-13.06.2020), 8723/- (DOA-13.07.2020), 27927/- (DOA-14.08.2020), 4990/- (DOA-14.10.2020). The HITPA/UIIC

has rejected these claims of chemotherapy day care treatment and has informed the reason: ‘As per documents submitted

the patient was admitted for carcinoma breast and underwent injection Trastuzumab, this treatment was not listed under day

care procedure hence the claim is recommended for repudiation under clause 3.3”. As per complainant, all the above claims

of chemotherapy day care treatment are very much covered and listed under Sr.No.13 (Chemotherapy including parental

chemotherapy) of clause 3.3 of relevant policy.

b) Insurers’ argument: The insured Smt. Shakuntla Sharma was suffering from Metastatic Carcinoma – breast. Various claims of

Rs. 324026/- were lodged by the insured. As per claim documents, patient was treated by intravenous administration of

injection Trastuzumab + Injection Zolendronic Acid + Tablet Anastrozole (oral) without any chemotherapy drug being

administered. Trastruzumab is a monoclonal antibody treatment and Zolendronic Acid is to treat the high level of calcium in

the blood while Anastrozole is a non-steroidal inhibitor, which blocks estrogen synthesis. The period of hospitalization was

less than 24 hours. As per clause 2.19, Hospitalization means admission in a hospital/nursing home for a minimum period of

24 in-patient care consecutive hours except for the specified day care procedures/treatments, where such admission could

be a period of less than 24 consecutive hours. The intravenous administration of injection Trastuzumab + Injection Zolendronic

Acid + Tablet Anastrozole (oral) without any chemotherapy drug being administered does not come under the list of

procedures mentioned under clause 3.3 of the policy. In view of the same the claims were repudiated under clause 2.19 and

3.3 of the policy. Company also informed that claim no. 201100113300 for Rs. 29610/- was inadvertently paid by them

subsequently on 15.12.2020 under the STU Policy. Hence the insured is claiming for balance Rs. 294416/-.

19. Reason for Registration of Complaint: Non-payment of health claims.

20 The following documents were placed for perusal:



21. Result of Personal hearing with both parties (Observations & Conclusion):


At this stage, the Insurers offer to admit and settle the claims including for the pre & post-hospitalisation, within 30 days. The

Complainant accepts this offer. Thus an agreement of conciliation could be arrived at between the Complainant and the

Insurers, which I consider as fair and reasonable for both the parties.

Award

The complaint is resolved in terms of the agreement of conciliation arrived at between the Complainant

and the Insurers. Accordingly, the Insurers shall admit and settle the claims including for the pre & post-

hospitalisation, within 30 days.

(Sudhir Krishna)

Insurance Ombudsman

August 20, 2021

PROCEEDINGS OF THE INSURANCE OMBUDSMAN, CHANDIGARH

(Under Rule 13 r/w 16 of The Insurance Ombudsman Rules, 2017)


Case of Narendra Singh Rana V/S The United India Insurance Co. Ltd.

Complaint Ref. No. : CHD-H-051-2021-0762

1. Name & Address of the

Complainant

Shri Narendra Singh Rana

Flat No. 740 FF, Block- TC, CHD City,

Sector- 45, Karnal, Haryana- 132001

Mobile No.- 9412843972

2. Policy No:

Type of Policy


5001002819P112263948

Group Health Policy

01-11-2019 To 31-10-2020



Narendra Singh Rana & Raj Dulari

Indian Bank’s Association, a/c PNB

4. Name of the insurer The United India Insurance Co. Ltd.


6. Reason for repudiation Day care treatment not allowed


8. Nature of complaint Repudiation of Claims

9. Amount of Claim Rs. 98267/-


11. Amount of relief sought Not specified

12. Complaint registered under Rule

no: Insurance Ombudsman Rules,

2017

Rule 13 (1)(b) – any partial or total repudiation of claim by an

insurer



For the Complainant Shri Narendra Singh Rana, the complainant

For the insurer Smt. Pamela Pinto, Deputy Manager (LCD), Mumbai

15 Complaint how disposed Recommendation under Rule 16


17. Brief Facts of the Case: Shri Narendra Singh Rana (hereinafter, the Complainant), has filed this complaint against the

United India Insurance Co. Ltd. (hereinafter, the Insurers) for non-settlement of health claims on his wife.


a) Complainants argument: His wife Smt. Raj Dulari was under the treatment of AIIMS Delhi and diagnosed NHL – B

(Cancer). The reimbursement of medical bills was in proper way but TPA of UIIC had stopped the payment without any

information. When contacted, TPA informed that there were changes in the policy during 2019-20. The unsettled claims

are for Rs. 35222, Rs. 16103/-, 14107/-, 8834/-, 24500/-. One bill of Rs. 5061/- had been passed for the same disease.

b) Insurers’ argument: Shri Narendra Singh Rana and spouse Smt. Raj Dulari covered under IBA –PNB retired employees

without domiciliary policy. Smt. Raj Dulari was suffering from Indolent B–Non Hodgins Lymphoma and undergoing

treatment for the same. Following claims were lodged by the insured:

Claim No. DOA- DOD Amount Claimed

201100068097 01.03.20 to 01.03.20 35222

201100088379 12.05.20 to 12.05.20 16104

201100193271 10.07.20 to 11.07.20 24500

201100193017 10.09.20 to 10.09.20 14107

201100193025 Pre post Hosp. expenses of Claim no.

201100193017

8334

Total 98267

As per claim documents, it was observed that the patient was being treated by intravenous administration of injection

Rituximab on standalone basis without any chemotherapy drug being administered. The period of hospitalization was

less than 24 hours. As per clause 2.19, hospitalization means admission in a hospital/nursing home for a minimum period

of 24 in-patient care consecutive hours except for specified day care procedures/treatments, where such admission

could be for a period of less than 24 consecutive hours. The administration of injection Rituximab, which is an antibody

therapy on standalone basis does not come under the list of procedures mentioned under Clause 3.3 of the policy. In

view of the same, the claims were repudiated citing clause 2.19 and 3.3 of the policy terms and conditions.

19. Reason for Registration of Complaint: Non-settlement of health claims.




21. Result of Personal hearing with both parties(Observations & Conclusion)


At this stage, the Insurers offer to admit and settle the claim as per the terms and conditions of the subject Policy, within

30 days. The Complainant accepts this offer. Thus an agreement of conciliation could be arrived at between the

Complainant and the Insurers, which I consider as fair and reasonable for both the parties

Award

The complaint is resolved in terms of the agreement of conciliation arrived at between the Complainant

and the Insurers. Accordingly, the Insurers shall admit and settle the claim as per the terms and

conditions of the subject Policy, within 30 days.

(Sudhir Krishna)

Insurance Ombudsman

27.08.2021

PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATE OF RAJASTHAN UNDER THE INSURANCE OMBUDSMAN RULES, 2017 (as amended till date)

OMBUDSMAN – SHRI C S PRASAD CASE OF HARI KISHAN SHARMA V/S THE NATIONAL INSURANCE CO.LTD

COMPLAINT REF: NO JPR-H-048-2122-0146 AWARD No. IO/JPR/H/A/2021/000

1. Name & Address of the

Complainant

Shri Hari Kishan Sharma

6/368, SFS, Agrawal Farm, Mansarover, Jaipur

2. Policy No:

Type of Policy

Commencement of the Risk

251100502010000379

Group Health Insurance (Canara Bank retirees)

01.11.2020 to 31.10.2021 SI- Rs.4 lacs




& Smt. Kusum Sharma (wife)


4. Name of the insurer The National Insurance Company Ltd


6. Reason for repudiation Repudiation of covid claim – day care treatment

not admissible


8. Nature of complaint Day care admission treated as domicile

treatment, hence disallowed

9. Amount of Claim Rs. 85125 +84460=169585/-

10. Date of Partial Settlement Nil



Rule no: of IOB rules

13(1) (b)

13. Date of hearing/place 24.08.2021 / Video Conferencing through

GoToMeeting


a) For the Complainant Shri Hari Kishan Sharma

b) For the insurer Shri Atul Malhotra, Dy. Manager

15 Complaint how disposed Award


17). Brief fact of the case : Shri Hari Kishan Sharma (herein after referred to as the complainant) had

filed a complaint against the decision of The National Insurance Company Ltd (herein after referred to

as respondent Insurance Company) alleging repudation of 2 mediclaims under group Health Insurance

policy bearing no. 251100502010000379.

18) Cause of Complaint:

Complainant’s argument: The complainant stated that he had under coverage of group health insurance

mediclaim policy taken by his employer from Respondent insurance company with risk commencement date

from 01.11.2020 to 31.10.2020 covering self and his wife. The complainant had consulted in OPD and on the

advice of doctor, he underwent for RTPCR and other test. He was declared covid positive on 13.11.2020 and

treated in OPD. On his deteriorating condition, he underwent HRCT and IL6 report on 14.11.2020 and

21.11.2020 with HRCT score of 3/25 and 9/25 and IL6 rating 9.9 and 82.74. Then on 22.11.2020 looking to his

severe health condition, the complainant rushed to the Eternal Hospital, where he was advised for admission in

day care and took treatment in day care from 22.11.2020 to 27.11.2020. Again , he was advised for HRCT on

29.11.2020. Similarly, his wife Smt. Kusum Lata Sharma had consulted in OPD and on the advice of doctor,

she underwent for RTPCR and other test. She was declared covid positive on 14.11.2020 and treated in OPD.

On his deteriorating condition, she underwent HRCT and IL6 report on 16.11.2020 and 22.11.2020 with HRCT

score of 9/25 and 13/25 and IL6 rating on 22.11.2020 was 66. Then on 23.11.2020 looking to her severe health

condition, the complainant rushed to the Eternal Hospital, where she was advised for admission in day care and

took treatment in day care from 23.11.2020 to 27.11.2020. Again on she was advised for HRCT on 29.11.2020.

Since the Hospital was authorized by the State Govt. for Covid treatment in Day care looking at the increasing

trend of Covid patients, hence the complainant submitted both the claims to the insurance company on

16.12.2020 of Rs. 84460 under claim no. 6013222 and of Rs. 85125 under claim no. 6013217 including pre and

post hospitalization. The insurance company had repudiated both the claim on 06.05.2021 on the ground that

domiciliary treatment was not covered under the policy as per clause 4.25. The complainant approached GRO

on 08.05.2021for reconsidering the both Mediclaims stating that EHCC hospital was allowed for treatment at

Day care Centre under government guidelines for treatment of covid-19 and most of the hospitals did not have

bed to accommodate. It was also not possible to keep enquiring about availability of bed in all the hospitals of

the city as timely treatment was more important to save the life rather than hospitalization. But the Insurance

Company did not reply to the complainant and Complainant did not get any relief from the Insurance Company.

Being aggrieved complainant approached this forum for redressal of his grievance.

Insurer’s argument:- The Insurance Company in its SCN dated 02.08.2021 submitted that both patients took

treatment of Covid-19. As per claim documents, it was observed that the patient was treated with Injection

Remdisivir on walk in basis/ day care basis and as per policy terms current procedure was not listed in day care.

Hence the claims have been repudiated as per policy conditions mentioned as per clause 2.19 i.e. hospitalization

means admission in a hospital/nursing home for a minimum period of 24 In-patient care consecutive hours except

fot the specified day care procedure/treatment. Hence the insurance company had prudently settled the claim

under purview of the policy guidelines

19) Reason for Registration of Complaint: Full repudiation of both mediclaims under health insurance

policy.

20) The following documents were placed for perusal.

a) Complaint letter

b) Copies of documents submitted by the complainant

c) Form VI A duly signed by the complainant.

d) SCN and a form VIIA duly signed by the Insurance Company

21) Result of hearing with both parties (Observations and Conclusion) :- The hearing in this case was

scheduled on 17.08.2021, but at the request of insurance company, the same was postponed for 24.08.2021.

Heard both the sides, the Complainant and the Insurance Company through video conferencing on 24.08.2021.

The Complainant submitted that he himself and his wife were in severe affected by Covid, which is evidenced

by the investigation report of PCR, HRCT and IL-6, but due to non availability of beds in the hospital, they had

no option, but to get their treatment in Day Care and also to avoid direct exposure. Further, the Covid treatment

taken in Day care was also allowed by the State Government vide order dated 28.11.2020, hence can not be

termed as Domiciliary treatment. The insurance company submitted that under the IBA policy, domiciliary

treatment was not covered; hence both the claims were rejected as per policy conditions.

On perusal of the documents exhibited and oral submissions made during the course of hearing, it is observed

that investigation reports of RTPCR, HRCT, IL-6 and administration of Remedesivir injection in Day care reveal

the deteriorating conditions of the patients. There was an active line of covid treatment given in the Day care.

Both the patients could not get the bed in the hospital due to increasing number of covid patient. Hence, the

Rajasthan Govt. also approved the treatment taken in Day care (established under supervision of Hospital).

Keeping in view all the facts and circumstances, the covid treatment taken in Day care centre is payable as per

the State Govt. Guidelines issued vide letter dated 03.09.2020 and 28.11.2020. Therefore, I direct the Insurance

Company to settle both the claims, as admissible treating the hospitalization as per Rajasthan State Government

guidelines issued for covid treatment on 03.09.2020 and 28.11.2020.

Accordingly, an Award is passed with a direction to the Insurance Company to settle the claim of the

insured, as admissible, treating the hospitalization for Covid treatment in compliance of State Govt.

guidelines issued on 03.09.2020 and 28.11.2020.

Award

Taking into account the facts and circumstances of the case and the submissions made by

both the parties during the course of hearing, the Insurance Company is directed to to settle

the claim of the insured, as admissible, treating the hospitalization for covid treatment as per

State Govt. guidelines issued for covid treatment on 03.09.2020 and 28.11.2020.

22. The attention of the Complainant and the Insurer is hereby invited to the following provisions of Insurance

Ombudsman Rules, 2017 (as amended till date):

a) According to Rule 17(5) of Insurance Ombudsman Rules, 2017(as amended till date), a copy of the award

shall be sent to the complainant and the insurer named in the complaint.

a) As per Rule 17(6) of Insurance Ombudsman Rules, 2017(as amended till date), the insurer shall comply

with the award within 30 days of the receipt of the award and intimate compliance of the same to the

Ombudsman.

Place: Jaipur C S PRASAD

Dated: 24.08.2021 INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF RAJASTHAN

UNDER THE INSURANCE OMBUDSMAN RULES, 2021 (as amended till date) OMBUDSMAN – SHRI C S PRASAD

CASE OF INDER SAIN V/S NATIONAL INSURANCE CO.LTD COMPLAINT REF: NO JPR-H-048-2122-0132

AWARD No. IO/JPR/H/A/2122/000 1. Name & Address of the Complainant Shri Inder Sain,

C/o Bank of Baroda, Katewa Chamber,

Opposite Dhan Mandi, Hanumangarh.

2. Policy No:

Type of Policy

Commencement of the Risk /S.I.

251100502010000273

Group Health Insurance

01.10.2020 to 30.09.2021/ Rs. 4 Lacs



Shri Jagdish Chander

Shri Inder Sain

4. Name of the insurer National Insurance Company Ltd

5. Date of Repudiation Undated (4 claims)

6. Reason for repudiation Treatment does not require 24 hours

hospitalization nor it is included in the Day

care procedure list as per clause 2.19


8. Nature of complaint Full Repudiation of mediclaim

9. Amount of Claim Rs.354998/- (4 claims)

10. Date of Partial Settlement N.A.




13(1) (b)

13. Date of hearing/place 24.08./2021/Through GoToMeeing


a) For the Complainant Shri Inder Sain

b) For the insurer Shri Atul Malhora, Dy. Manager



17). Brief fact of the case : Shri Inder Sain (herein after referred to as the complainant) had

filed a complaint against the decision of National Insurance Company Ltd (herein after referred

to as respondent Insurance Company) alleging repudiation of 4 claims under Health Insurance

policy no. 251100502010000273.


Complainants’ argument: The complainant stated that he had under health insurance coverage

of group mediclaim policy taken by his employer (BOB) from Respondent insurance company

with risk commencement date from 01.10.2020 to 30.09.2021 including his father Shri Jagdish

Chander. The Insured was a patient of CA Tongue and had taken treatment in SP Medical

College, Bikaner for Chemotherapy (immunotherapy) by Injection “Opdyta”(Nivolumab) 4

times admitted in the hospital on 10.12.2020 25.12.2020, 08.01.2021 and 22.01.2021 and

discharged on 14.12.2020, 26.12.2020, 09.01.2021 and 23.01.2021 after treatment. The

Mediclaim for reimbursement of the treatment taken were submitted by the Complainant to the

Insurance Company under claim no. 23603745, 23804006, 23825757 & 23933689 for Rs.

354998 which were repudiated by Insurance Company on undated on the ground that Adjuvant

therapy/monoclonal Antibody is standalone treatment for this particular admission and the

procedure is not list under the day care procedure as per clause no.2.19. The complainant again

approached the GRO on 19.04.21 for considering the Mediclaim But the Insurance Company

reiterated the decision. Being aggrieved, complainant approached this forum for redressal of his

grievance.

Insurers’ argument:- The Insurance Company in its SCN dated 07.07.2021 submitted that

Insured was diagnosed with Ca Tongue, taking chemotherapy (immunotherapy) in Sardar Patel

Medical College and PBM Hospital, Bikaner. The patient was taking Injection Nivolumab on

regular basis in day care treatment. This is immunotherapy drug, not accompanied by any other

active chemotherapy agent, is not payable standalone and also not covered in Day care List and

also 24 hours hospitalization was not completed. Inj.NIVOLUMAB (OPDYTA) 200 mg which,

as per available medical literature, is an immune therapy drug. This can not be termed as

Chemotherapy. These claims were rejected on the ground that this was a monoclonal antibody

and is given on day care basis and also not required hospitalization for 24 hours. Hence all the

claims were repudiated as per the policy clause no. 2.19 – “Procedure/treatments usually done

in outpatient department are not payable under the policy even if admitted/converted as an in-

patient in the hospital for more than 24 hours. Therefore the Respondent has repudiated the claim

in accordance with the terms and condition of the policy Clause no. 2.19.

19) Reason for Registration of Complaint: Total repudiation of mediclaim under health

insurance policy.


a) Complaint letter




21) Result of hearing with both parties (Observations and Conclusion) :- The hearing

in this case was scheduled on 17.08.2021, but at the request of the insurance company, the same

was postponed for 24.08.2021. Heard both the sides, the complainant and the Insurance

Company through video conferencing. The complainant submitted that his father had been

taking treatment of Chemo therapy and immunotherapy for the last 2 years in PBM Hospital,

(Govt. Hospital) and the claims rejected by the insurance company were not justified, as the

treatment was taken on the advice of the treating doctor.

The Insurance Company reiterated that the Immunotherapy alongwith chemotherapy was

payable as per policy condition, whereas the Immunotherapy given standalone was not payable.

Further, it was stated that this treatment is not listed in the day care treatment list. Therefore, all

the claims were not payable.

On perusal of the documents submitted and oral submission made during the course of hearing,

it is noted that the patient is undergoing cancer treatment in the govt. hospital for the last two

years. Further, it is found that the patient was advised hospitalization under day care for cancer

treatment for immunotherapy by the treating doctor for infusion of injection under close

observation, which was necessary keeping in view of the condition of the patient. It is the treating

doctor to decide the immunotherapy to be given standalone or with chemotherapy as per the

patient condition, hence active line of treatment can not be questioned. Keeping all aspects in

view, the Insurance Company is directed to settle all the four claims as admissible.

Award Taking into account the facts and circumstances of the case and the submissions made by

both the parties during the course of hearing, the Insurance Company is directed to settle all

the four claims to the insured, as admissible.

22. The attention of the Complainant and the Insurer is hereby invited to the following provisions

of Insurance Ombudsman Rules, 2021(as amended till date):

a. According to Rule 17(5) of Insurance Ombudsman Rules, 2021(as amended till date), a copy

of the award shall be sent to the complainant and the insurer named in the complainant.

b. As per Rule 17(6) of Insurance Ombudsman Rules, 2021(as amended till date), the insurer shall

comply with the award within 30 days of the receipt of the award and intimate compliance

of the same to the Ombudsman.



PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATE OF RAJASTHAN UNDER THE INSURANCE OMBUDSMAN RULES, 2017 (as amended till date)

OMBUDSMAN – SHRI C S PRASAD CASE OF POORAN CHANDRA PAREEK V/S NATIONAL INSURANCE CO.LTD

COMPLAINT REF: NO JPR-H-048-2122-0140 AWARD No. IO/JPR/H/A/2122/000

1. Name & Address of the Complainant Shri Pooran Chandra Pareek,

81, Pratap Nagar, Khatipura Road, Jaipur

2. Policy No:

Type of Policy

Commencement of the Risk /Policy

period Sum Insured

251100502010000336

Group Health Ins. (Indian Bank Retirees)

01.11.2020 to 31.10.2021

Rs.3 lacs



Shri Pooran Chandra Pareek

Shri Pooran Chandra Pareek

4. Name of the insurer National Insurance Company Ltd

5. Date of Repudiation 13.01.21 (RE) and 22.04.21 (LE)

6. Reason for repudiation Partial settlement as per reasoble & customary

clause


8. Nature of complaint partial repudiation of the mediclaim

9. Amount of Claim Rs. 1200 + 6000 = 7200

10. Date of Partial Settlement 13.01.21 (RE) and 22.04.21 (LE)

11. Amount of relief sought Rs. 7200



13(1) (b)

13. Date of hearing/place 24/08//2021 Jaipur Through GoToMeeting app

video conferencing


a) For the Complainant Shri Poonam Chanra Pareek

b) For the insurer Shri Atul Malhotra, Dy. Manager



17). Brief fact of the case : Shri Pooran Chandra Pareek (herein after referred to as the complainant) had filed a

complaint against the decision of National Insurance Company Ltd (herein after referred to as respondent Insurance

Company) alleging partial settlement of mediclaim under Group Health Insurance policy no. 251100502010000336.


Complainant’s argument: The complainant stated that he had under coverage of group health insurance policy for Sum

insured of Rs. 300000/- taken by his employer from Respondent insurance company with risk coverage from 01.11.2020

to 31.10.2021. The Insured himself was admitted in the KC Memorial Eye Hospital, Jaipur for cataract operation in his

right eye on 27.11.2020 and left eye on 28.01.2021 and discharged from the hospital on next day. After discharge from

the hospital, the complainant lodged the mediclaim for reimbursement of Rs.30088 & 28484 under claim no.

HH172107525 (08.12.2020) & HH172120582 (05.02.2021) to the insurance company. The claim of RE was partially

settled by the insurance company on 13.01.2021 deducting Rs. 1200 towards Corona Test Charges and the claim of LE

was partially settled by the insurance company on 22.04.2021 deducting Rs. 6000 on the ground of reasonable and

customary clause. The complainant represented his case to GRO on 24.01.2021 to reconsider his case that corona test

was compulsory before cataract operation and it was advised by the treating doctor. Further he represented his second

claim of LE was represented to GRO on 31.05.2021 to reconsider his case that earlier in the RE cataract claim all charges

were passed by the insurance company except corona test charges, then in the claim of LE cataract deduction made on the

reasonable and customary ground was not justified. But the insurance company reiterated its decision again and he did

not get any relief from the Insurance Company. Being aggrieved complainant approached this forum for redressal of his

grievance.

Insurer’s argument:- The Insurance Company in its SCN dated 02.08.2021 submitted that the bill no. KK-944 dated

23.11.2020 of Rs. 1200 incurred for covid Test were deducted as the credit bill was not acceptable and from the Second

bill Rs. 1000 (Room Rent), Rs. 1000 (Anesthetist Charges) and Rs. 4000 (OT charges) were deducted as per reasonable

and customary clause. Therefore, the insurance company had settled the claim as per the terms and conditions of the

policy.

19) Reason for Registration of Complaint: Partial repudiation of mediclaim under health insurance policy.


a) Complaint letter




21) Result of hearing with both parties (Observations and Conclusion) Both the complainant and the Insurance

Company were heard through online hearing on 24.08.2021. The complainant submitted that corona test was compulsory

before cataract operation and it was advised by the treating doctor. Further, he represented that earlier in the RE cataract

claim all charges were passed by the insurance company except corona test charges, then in the claim of LE cataract

deduction made on the reasonable and customary ground was not justified. The Insurance Company reiterated its decision

that Rs. 1200 incurred for covid Test were deducted as the credit bill was not acceptable. Further, during the course of

discussion, it was submitted by the insurance company that both the claims would be reviewed again in the light of

submission made by the complainant. On the next working day, it is informed by insurance company that they have

initiated the process for settlement of both the claims for Rs. 1200 and Rs 6000 and payment will be made in the due

course.

On perusal of the documents exhibited and oral submissions made during the course of hearing, it was observed that the

insurance company had reviewed both the claims and ready to settle the claims and initiated the payment process.

Accordingly, an Award is passed with a direction to the Insurance Company to pay the claims to the insured as agreed

under intimation to this office.

AWARD

Taking into account the facts and circumstances of the case and the submissions made by

both the parties during the course of hearing, the Insurance Company is directed to pay the

claim to the insured, as agreed.

22. The attention of the Complainant and the Insurer is hereby invited to the following provisions of Insurance Ombudsman

Rules, 2017(as amended till date):

a. According to Rule 17(5) of Insurance Ombudsman Rules, 2017 (as amended till date), a copy of the award shall

be sent to the complainant and the insurer named in the complaint.

b. As per Rule 17(6) of Insurance Ombudsman Rules, 2017 (as amended till date), the insurer shall comply with

the award within 30 days of the receipt of the award and intimate compliance of the same to the Ombudsman.



AWARD NO.IO/KOC/A/HI/0182/2021-2022

PROCEEDINGS OF

THE INSURANCE OMBUDSMAN, KOCHI

(UNDER RULE NO. 13 1(b)READ WITH RULE 14 OF

THE INSURANCE OMBUDSMAN RULES, 2017)

Complaint No.KOC-H-051-2122-0273

PRESENT: Ms. POONAM BODRA

INSURANCE OMBUDSMAN, KOCHI.

AWARD PASSED ON

1. Name and Address of the complainant

: Mr. Ramachandran Nair B

Karthika, TC 64/687, VNRA 43, Kannamcode

Junction, Karumamom, Karamana P O,

Trivandrum - 695002

2. Policy Number

: 5001002819P111833956

3. Name of the Insured

: Mr. Ramachandran Nair B

4. Name of the Insurer

: The United India Insurance Co. Ltd.

5. Date of receipt of Complaint

: 21.06.2021


: Rejection of mediclaim

7. Amount of relief sought : --

8. Date of hearing

: 12.08.2021

9. Parties present at the hearing

a) For the Complainant

: Settled before hearing

b) For the Insurer :

AWARD

This is a complaint filed under Rule 13 1(b) read along with Rule 14 of the Insurance Ombudsman Rules, 2017. The

complaint is regarding rejection of mediclaim. The complainant, Mr. Ramachandran Nair B is the policyholder.

1. Averments in the complaint are as follows:

The Complainant. A 65 years old pensioner, stated that he is insured under IBA Corporate Policy for retirees. He lodged

a claim for Rs.5918/- on 23/3/2021. In spite of repeated reminders, there is no response from the Ins. Co. He requests

the Ombudsman to award Rs. 5,918/- besides compensation of Rs.5,000/- for mental agony and interest at the rate of

8.25% plus 2% of claim amount from 21/3/2021 till date of credit to his account as per Regulation No. 14(2)(ii) of PPI

Regulations, 2017.

2. The Respondent Insurer entered appearance and filed a self contained note. It is submitted that they have decided to

settle the claim.

3. The claim has been settled by the Respondent Insurer for Rs. 4,780/- vide UTR No. CITIN21217832968 dated 9-8-

2021.

In the result, an AWARD is passed for Dismissal of the complaint.

Dated this the 12th day of August 2021

Sd/-

(POONAM BODRA)

INSURANCE OMBUDSMAN


PROCEEDINGS OF

THE INSURANCE OMBUDSMAN, KOCHI






AWARD PASSED ON 16.08.2021


: Mr. Prabhakaran Nair V

Dhanasree T C, 7/1652(1), Sreechitra Nagar,

Pangode, Thirumala, Trivandrum - 695006

2. Policy Number

: 5001002818P113283453


: Mr. Prabhakaran Nair V




: 26.04.2021



7. Amount of relief sought

: --

8. Date of hearing

: 12.08.2021



: Consent Given

b) For the Insurer : Ms.Pamela pinto(Online)

AWARD


complaint is regarding rejection of mediclaim. The complainant, Mr. Prabhakaran Nair V is the policyholder.


The Complainant stated that he is insured under IBA Corporate Policy for retirees. He had lodged 2 claims on 26/7/2019

for Rs.18,939/- for himself and Rs. 21,443/- for his wife. Subsequently details of admission, discharge and diagnosis under

Ayurveda System of treatment was furnished besides other documents called for on various dates. There was no need

of X-ray, Scan etc. While his wife’s claim was settled on 16/10/2020, his claim was not settled. There is indifference on

the part of the Ins. Co. While they are settling some claims, they are not settling others. He requests the Ombudsman to

award Rs. 18,939/- and interest at the rate of 8.25% plus 2% of claim amount from 26/7/2019 till date of credit to his

account as per Regulation No. 14(2)(ii) of PPI Regulations, 2017, besides compensation of Rs.5,000/- for mental agony.

2. The Respondent Insurer entered appearance and filed a self contained note. It is submitted that a group Mediclaim

policy was issued to INDIAN OVERSEAS BANK RETIRED EMPLOYEE (OPTION I): 500100/28/18/P113283453 for period 01-

Nov-2018 To 31-Oct-2019.

Mrs Indira D (Employee No. 43951) is included by Indian Overseas Bank in the list of retired employees along with her

spouse Mr. Prabhakaran Nair V.

Mr. Prabhakarn Nair V had submitted a reimbursement claim for treatment of Chronic Polyarthritis taken at

Pankajakasthuri Ayurveda Medical College Hospital - Thiruvananthapuram. The claim is lodged with claim no.

MDI5107338 / 5001002819C339696001. The retiree claimed for Rs. 18,939/- under this claim.

The claim observations are :

a. 67 yrs male patient was admitted for Chronic Polyarthritis with complaints of pain and numbness on both shoulder

joints radiating to fingers since 3 years and low back ache since 3 years.

b. The admission was 17-Jul-2019 To 26-Jul-2019

c. Documents were submitted on 16/08/19.

d. Queries rasied on 22 /08/19 in this case were :

i. Please provide Initial Case Papers, clinical summary or first consultation papers, showing the nature/duration/history

of Illness along with FREQUENCY OF EACH AYURVEDIC PROCEDURE GIVEN DURING HOSPITALIZATION, referral letter for

investigation or specialist’s consultation paper.

ii. As per claim documents received, it has been observed that the Claim Intimation was not given to us within [ 24 ]

hours after admission in hospital. Kindly submit the reason for delay along with IC approval.

iii. There was a delay of 18 days in submission hence reason for delay along with IC approval is required.

iv. The claim is closed, as requisite documents are not provided inspite of Additional Document Request letters dated

11/09/2019 and 01/10/2019

Reply received from retiree were on 3/1/20, 11/02/20, 16/3/20 and 30/07/20, which was after closure of the claim.

3. I heard the Respondent Insurer. The Complainant stated that he is not in a position to attend online Hearing or in

person and gave consent for resolution of the complaint in his absence .The Respondent Insurer submitted that the

claim was not intimated within 24 hrs. as stipulated in the policy . The Indoor Case Papers and other documents were

submitted after a long period of time, by when they had closed the claim.

4. I have heard the Respondent Insurer and perused the documents submitted by either side. I find that there was some

delay on the part of the Complainant in replying to the queries raised by the Respondent Insurer . However, I find that

the claim is tenable and the Admissible Claim Amount is Rs. 18,347 /-

In the result, an award is passed, directing the Respondent Insurer to pay an amount of Rs. 18,347 /- , within the

period mentioned hereunder. No cost.

As prescribed in Rule 17(6) of Insurance Ombudsman Rules, 2017, the Insurer shall comply with the award within 30 days

of receipt of the award and intimate compliance of the same to the Ombudsman.


Sd/-

(POONAM BODRA)

INSURANCE OMBUDSMAN


PROCEEDINGS OF THE INSURANCE OMBUDSMAN, KOCHI








: Mr. Cherian Urmis

(Pass No.131/1,CIAL Prepaid Taxi Society

NO.E998 Nedumbassery) Puthussery House

Thettali Chowara 683571

2. Policy Number

: 1001002819P116739641


: Mr. Cherian Urmis




: 24.06.2021


: Rejection of mediclaim (Covid)


: --

8. Date of hearing

: 12.08.2021



: Mr. Cherian Urmis (Online)

b) For the Insurer : Muhammed Shajir (Online)

AWARD


complaint is regarding rejection of mediclaim. The complainant, Mr. Cherian Urmis is the policyholder.


The Complainant stated that he is covered under Group Insurance . He had out patient consultation on 1/3/2021, in Lisie

Hospital, authorised hospital under the Society’s Group Insurance Scheme, for serious symptoms of vomiting and cough.

The Doctor prescribed medicines for a month although he was feeling weak and wanted to get admitted. On 5/3/2021,

he could not even sit up and he fell unconscious on the way to Lisie Hospital and so was admitted to Renai Medcity.

They confirmed Covid19 , with pneumonia and stated that his lungs were badly affected. CIAL TOCS officials did nothing

to get approval for hospitalization at Renai Medcity and hence claim was repudiated by the Ins. Co. The CIAL TOCS did

not provide him list of approved hospitals and it is learnt that insurance coverage is primarily meant for Society’s Board

members and not for ordinary members. Recently the Society has changed the Ins. Co. but have not provided coverage

details to the members.

2. The Respondent Insurer entered appearance and filed a self contained note. It is submitted that Group Health

Insurance Policy – 1001002819P11673964 has been issued for the period from 29/03/2020 to 28/03/2021 to Insured –

M/s CIAL Taxi Operators Co-Op Society Ltd No E998.

The Policy Covers 557 Members and their family of CIAL Taxi Operators Co-op Society Ltd No.E998. Family Members

include Self, Spouse, Dependent Children and Parents or Parents In Laws. The sum insured is Rs.1,50,000/- per family on

floater basis. Claim serviced by TPA M/s.Health India Insurance TPA of India.

Special Condition: Treatment restricted to below 10 listed hospitals as specified by the insured (M/s CIAL Taxi Operators

Co-op Society). However in exigent situations treatment in other hospital shall be considered on approval from the

society and the same will be communicated through Insurance Agent Smt Ramya Tineesh (working in M/s Struck

Consultants a firm run by her husband Tineesh)

1. Little Flower Hospital Angamaly

2. MAGJ Hospital Mookannoor

3. St James Hospital, Chalakudy

4. Karothukuzhi Hospital, Aluva

5. Giridhar Eye Hospital, Kadavanthara, Ekm

6. San Joe Hospital, Perumbavur

7. Lisie Hospital, Edappally

8. Amritha Hospital, Edappally

9. Lourde Hospital, Ernakulam

10. Vimala Hospital, Kanjoor.

Claim Details: The Insured, Shri Cherian Urmis 67 years old has covered under the policy Sl. No.131/1 for Sum Insured of

Rs.1,50,000/-. He underwent treatment at Renai Medicity for Covid 19 positive during the period 05/03/2021 to

18/03/2021. Total Hospitalisation Bills amounts to Rs.2,09,543/-. The TPA had repudiated the claim on the reason that

treatment has not taken in the above listed hospitals as per the policy condition. Shri Cherian Urmis has lodged a

grievance and respondent insurer had sent several letters and reminders to both Secretary of CIAL Taxi Co-op Society

and the agent Ramya Tineesh to get their decision on special approval for considering it as exigency. But both of them

have not responded. In the absence of their consent we agree with the decision taken by the TPA and conveyed the

decision to Shri Cherian Urmis.

Prayer: The complaint lodged by Shri Cherian Urmis is not against Insurer-United India Insurance Co. It is actually a

complaint against the society in which he is a member and they are suggesting policy terms and conditions. The Society

is not willing to recommend his hospitalisation in spite of several reminders. So it is clearly a dispute between Co-

Operative Society and one of its member.

The respondent insurer requests the Hon’ble Ombudsman to dismiss the complaint.

3. I heard the Complainant and the Respondent Insurer. The Complainant submitted that he had asked the Society Board

Members and the Society Agent called him a fraud and said that they are not allowing him any consent of approval . The

Respondent Insurer submitted that the complainant reported that he fainted on the way and so he was admitted in a

hospital other than in the list. The Society was contacted several times but they did not show any interest in granting

special approval.

4. I have heard both the sides and perused the documents. Unless the CIAL Taxi Co-op Society sends approval to the

Respondent Insurer, the claim cannot be paid. The complainant has to himself pursue approval from his Society. The

Society’s deficiency in service, if any, is outside the scope of this Forum.



Sd/-

(POONAM BODRA)

INSURANCE OMBUDSMAN



(UNDER RULE NO. 13 1 (b) READ WITH RULE 14 OF


Complaint No. KOC-H-016-2122-0188





: Mrs. Remya A

C/o Lido Rubber Products, I.D.Plot,

West Hill, Kozhikode - 673005

2. Policy Number

: CRP-39-20-7532657-00-000


: Mrs. Remya A


: Future Generali India Insurance Co. Ltd.


: 30.04.2021


: Rejection of mediclaim (Covid)


: --

8. Date of hearing

: 03.08.2021



: Mrs. Remya A (Online)

b) For the Insurer : Dr. Akamsha Saxena(online)

AWARD

This is a complaint filed under Rule 13 1 (b) read along with Rule 14 of the Insurance Ombudsman Rules, 2017. The

complaint is regarding rejection of mediclaim. The complainant, Mrs. Remya A is the policyholder.


The Complainant stated that she had taken a Corona Rakshak policy in July 2020 along with about 100 employees of her

company, Lido Rubber Products(Hawalker Brand). During November`20, when consulted for fever, chest pain & throat

pain at the Kozhikode Corporation Dispensary, she was referred for Covid test at the Kozhikode Beach Hospital and was

tested Covid positive. Upon reference from the Primary Health Centre , Cheruvannur, she was admitted at the FLTC

Farook College, on 13.11.20 and thereafter was discharged on 21.11.20, on testing Covid negative. All documents for

claiming were submitted with the respondent insurer. But her claim was denied stating that, the Inpatient care means

treatment for which the insured has to stay in the hospital continuously for more that 72hours for treatment of Covid.

Her admission at the FLTC was for 9days. She lodged a complaint with the respondent insurer at Kozhikode from where

it was informed to her that the policy was taken from there their Ernakulam Office and to contact that office. The

complainant mailed all documents at the respondent`s Ernakulam, but did not receive reply. The Complainant prayed

for the settlement of the claim. The effective policy period was from 16.7.20 to 26.4.21 and the sum insured is Rs.2.5lacs.

2. The Respondent Insurer entered appearance and filed a self contained note. It is submitted that a Corona

Rakshak Policy, Policy no- CRP-39-20-7532657-00-000 was issued for the period 16-July-20 to 26-Apr-21 . The total claimed amount was INR 250000. The insured had undergone hospitalization at Covid First Line Treatment Centre, for Covid-19 Positive. As per the discharge summary there were no clinical features (symptoms or signs) that necessitated hospitalization. The patient was presented to the hospital with Headache, Fever & Sore Throat. The vital parameters were not captured at the admission implying that the patient was stable. As per Circular issued by Government MOHFW dated 17th-Mar-20, Mild Symptoms does not require hospitalization. Furthermore as per the Operative Clause of the policy, the admission has to be as per guidelines specified by MOHFW.

The circular issued by Government of Kerala vide no. 31/F2/2020/Health date 28th March 2020 defines first line treatment centre.

Definition: The centre identified as Covid Health care Centre should treat all mild and moderate symptomatic persons

under surveillance and should be utilized for treating positive cases, when need arise they are primary level health care

centers for providing care to less serious cases and referral of serious cases to the Covid Hospitals to avoid crowding

directly in the Covid Hospital and wastage of resources.

To have an unbiased decision on the claim, an opinion of the Independent Forensic Expert was sought. As per the

forensic expert, the complainant was hospitalized mainly for isolation/ observation/ evaluation purposes only. Her

isolation/ observation/ evaluation and treatment for symptoms faced which could easily have been managed on

domiciliary basis. Thus, taking cognizance of all the above factors and govt. guidelines, the claim was repudiated.

3. I heard the Complainant and the Respondent Insurer. The Complainant submitted that she was admitted at the FLTC

Farook College, on 13.11.20 on testing covid positive and thereafter was discharged on 21.11.20, on testing Covid

negative. She had fever, chest pain & throat pain and consulted the Kozhikode Corporation Dispensary, from where she

was referred for Covid test at the Kozhikode Beach Hospital and was tested positive. On reference from the Primary

Health Centre , Cheruvannur, she was admitted at the FLTC Farook College . Her claim was rejected stating that the

Inpatient care means treatment for which the insured has to stay in the hospital continuously for more that 72hours for

treatment of Covid. The Respondent Insurer submitted that the complainant had undergone hospitalization at Covid

First Line Treatment Centre, for Covid-19 Positive. According to the discharge summary, there were no clinical features

(symptoms or signs) that necessitated hospitalization. The complainant was presented to the hospital with Headache,

Fever & Sore Throat. The vital parameters of the insured were not captured at the admission, implying that the patient

was stable. As per Circular issued by Government MOHFW dated 17th-Mar-20, Mild Symptoms does not require

hospitalization. To have an unbiased decision on the claim, an independent opinion from an independent forensic expert

was taken. According to the forensic expert,the complainant was hospitalized mainly for isolation/ observation/

evaluation purposes only. Her isolation/ observation/ evaluation and treatment for symptoms faced which could easily

have been managed on domiciliary basis. The claim was denied.

4. I heard the complainant and the respondent insurer and had gone through the records submitted . In this complainant where the complainant`s claim under the Corona Rakshak was denied the arguments put forth by the respondent insurer were :-1.The insured had underwent hospitalization at theCovid First Line Treatment Centre, for Covid-19 Positive. 2. There were no clinical features (symptoms or signs) that necessitated hospitalization as per the discharge summary. 3.The patient was presented to the hospital with Headache, Fever & Sore Throat.4. The Vital parameters were not captured at admission implying that the patient was stable.5. As per Circular issued by Government MOHFW dated 17th-Mar-20, Mild Symptoms does not require hospitalization.6.The circular issued by Government of Kerala vide no. 31/F2/2020/Health date 28th March 2020 defines first line treatment centre.7.As per the independent Forensic Expert, the complainant was hospitalized mainly for isolation/ observation/ evaluation purposes only. Her isolation/ observation/

evaluation and treatment for symptoms faced could have been managed on domiciliary basis; are all tenable. I therefore do not want to interfere in the decision of the respondent insurer in denying the claim.



Sd/-

(POONAM BODRA)

INSURANCE OMBUDSMAN



(UNDER RULE NO. 13 1(b) READ WITH RULE 14 OF







: Mr. Sabu Joseph

Nedumthottiyil House Onamthuruth

Athirampuzha P O Kottayam 686631

2. Policy Number

: 2876/00111671/000/00


: Mrs. Jomon Sabu


: Cholamandalam MS Gen. Insu.Co. Ltd


: 11.06.2021




: --

8. Date of hearing

: 12.08.2021



: Mr.Sabu Joseph (Online)

b) For the Insurer : Dr. Prabhu (Online)

AWARD


complaint is regarding rejection of mediclaim. The complainant, Mr. Sabu Joseph is the policyholder.


The Complainant stated that his wife was admitted for umbilical hernia repair on 8/4/2021 with the permission of the

Ins. Co. for Cashless treatment for an amount of Rs. 50,000/- but at the time of discharge they denied the payment. They

later stated that there was non-disclosure of a minor surgery done earlier. He requests the Ombudsman to take a decision

in the matter.

2. The Respondent Insurer entered appearance and filed a self contained note. It is submitted that the subject mentioned

policy is a group health policy issued in the name of complainant Mr Sabu Joseph for the period effective from

27/01/2021 to 26/01/2022 for sum insured of Rs 300000 / which is subject to terms , conditions and exclusions of the

policy.

The claimant’s wife Mrs. Jomol Sabu was admitted to Caritas Hospital from 07/04/2021 to 10/04/2021 for para

umbilical hernia.

Upon submission of medical documents it was mentioned in the discharge summary that she had past history of HTN

on treatment, history of Bowen’s disease, status post excision 2 years ago

Hence this respondent had repudiated the claim vide its letter dated 28/05/2021 on the following grounds which is

re-iterated here under-

On perusal of the claims documents, the insured is having Bowens disease since 2 years as per the history recorded in

the discharge summary, this information is not disclosed in the proposal form while proposing for insurance. In view of

this non-disclosure of material information, the contract of insurance becomes void and no claim is payable under this

policy

Hence for the above mentioned reasons, this respondent is not in a position to honour the claims. Hence the claims of

the petitioner was repudiated on just and reasonable grounds of the policy wordings. The complaint is to be dismissed

3. I heard the Complainant and the Respondent Insurer. The Complainant submitted that his claim was not settled.

Initially he stated that he had signed the proposal himself but later stated that the proposal was signed by Ins. Co.’s

agent. The Respondent Insurer submitted that the complainant’s wife is a k/c/o HTN and Bowen’s Disease. The same

was not disclosed at the time of taking the policy.

4. I have heard both the sides and perused the documents. It is observed that the signature in the Proposal Form

submitted to the Ins. Co. at the time of taking the policy and the signature in the Complaint submitted to this Forum are

not the same. The signature in Annexure VIA submitted to this Forum does not match with the signature in the

Complaint submitted to this Forum. The identity of the complainant is therefore, not established.

Notwithstanding the above, it is noted from the Discharge Summary that the complainant’s wife is a k/c/o HTN with h/o

Bowens Disease. These Pre Existing Diseases were not disclosed by the complainant while taking the policy . The claim is

not tenable, since Pre Existing Diseases are an exclusion under the policy: Exclusion: 3.2 Pre-Existing Disease (PED) -

Benefits will not be available for any pre-existing condition(s) as defined in the policy, until 24 consecutive months of

continuous coverage have elapsed, since inception of the first policy. Besides, in accordance with General Conditions

4.16, the policy shall be void in the event of non-disclosure of any material fact by the insured person(s).



Sd/-

(POONAM BODRA)

INSURANCE OMBUDSMAN



(UNDER RULE NO. 13 1(c) READ WITH RULE 14 OF







: Mrs. Lissy Kuriakose

Kuttichirakudiyil House, Oonnukal P.O,

Ernakulam 686693

2. Policy Number

: OG-18-1602-6021-00000239


: Mrs. Lissy Kuriakose


: Bajaj Allianz General Insc Co. Ltd.,


: 24.09.2020


: Continuation of policy


: --

8. Date of hearing

: 13.08.2021



: Mrs. Lissy Kuriakose (Online)

b) For the Insurer : Ms. Reshma, Mr. Ravindra Shinde,

Mr. Roshan Goyal (Online)

AWARD

This is a complaint filed under Rule 13 1(c) read along with Rule 14 of the Insurance Ombudsman Rules, 2017. The

complaint is regarding continuation of policy. The complainant, Mrs. Lissy Kuriakose is the policyholder.


The Complainant submitted that her Group Health Insurance Policy was going smoothly for almost 10 years with the

Chola MS till March 2017, with the premium being auto deducted from her South Indian Bank S B Account,

Kothamangalam and auto renewed accordingly. Without her consent, the South Indian Bank, kothamangalam changed

the Insurance provider from Chola MS to Bajaj allianz in April 2017. The policy had the following errors- The name of her

husband Late Mr. Kuriakose (who passed away in 2015 May, who was the primary insured) incorrectly entered as

Kuriakose K Krishnan, deletion of the person from the policy would have been considered instead.

Both the insured, Late k I Kuriakose and Mrs Lisy Kuriakose has the Date of Birth (age) wrong as 17-Jul-1953(65 yrs).

Correct Date of birth is 17 Jul 1950 (67 yrs then)

Scope of cover 2 is 18 yrs to 65 yrs. Luckily there wasn’t any claim requests made or else her name / age wouldn’t have

matched with the hospital documents.

The premium amount of Rs.5922/- was deducted twice on 3rd and 13th of March 2017 for the year 2017-18 health cover.

The details of which are entered in the bank statement as paid to Cholamandalam instead of Bajaj Allianz. So the change

in insurance provider was marked initially. Because of which few communications were made with Chola MS regarding

the refund of the double deduction.

While the extra premium in credit, in 2018 premium amount of Rs.6784/- was paid with all the mistakes intact. This time

also the beneficiary name entered in the Bank statement as Chola MS instead of Bajaj allianz. For the year 2018, the

complainant has not received any policy yet. While the policy was with Chola MS(10 yrs) the premium were auto

deducted from her SIB Kothamangalam Bank account in the second week of March, but this didn’t happen in 2019 and

so her health insurance stays cancelled. No reminders / communications were made from the Bank or insurance provider

regarding this.

It is submitted that the complainant is a 70 year old widow who had to suffer the irresponsibility of the Bank and the

insurance provider. She lost the health insurance cover/benefit (No claims) with Chola MS for 10 years. And constantly

contacting the SIB, Kothamangalam & Bajaj Allianz for 3 years and no help rendered from both. Since she is exhausted,

she is raising the issue now. Most of the insurance companies don’t provide insurance cover for 70+ age group or if at all

they provide health cover it is of high premium and can get the reimbursement of only 70% of the hospital bills.

2. The Respondent Insurer entered appearance and filed a self-contained note. It is submitted that all averments in the complaint except those that are specifically admitted or dealt with hereunder are denied by the respondent. It is hereby submitted that this respondent had issued policy bearing OG-18-1602-6021-00000239 to the complainant covering the period 26-MAR-2017 to 25-MAR-2018. The said policy was issued with Mr. Kuriakose K I as the insured on the basis of the information given by the South Indian Bank. This Respondent had not received any request from the complainant seeking for correction in the name and age. Moreover, this respondent was not aware of any such correction to be made. Further there is a 15 days look in period, in which the insured can approach for any correction in the policy, but the complainant failed to do so and she had not approached this Insurance Company for any correction in the policy, which means she had accepted the policy which was issued to her in 2017. The averment that the premium of Rs.5922/- was deducted twice was without our knowledge. It was deducted by the South Indian Bank. It is admitted by the complainant that the she has received the excess premium so collected. So this respondent is not liable. This respondent is not liable to deduct premium amount from the account of the complainant. The premium is debited by the bank themselves. The mistake in the entry made in the passbook stating that premium was paid to Cholamandalam instead of us is not within the knowledge of this Respondent. The Premium is debited by the South Indian Bank and thereafter it is paid to us. The complainant had not approached this respondent seeking for renewal of the policy. The claim of the Complainant is that the premium used to get auto deducted from her South Indian Bank account in the 2nd week of March, but that did not happen in 2019. It is submitted that before expiry of the policy OG-18-1602-6021-00000239, this Respondent had intimated the South Indian Bank for renewal of the policy of the complainant vide e mail dated 23-02-2018 (annexed).To this email there was no response from south Indian Bank. Further this Respondent received the premium after 88 days from the expiry of the policy i.e. only on 21-June-2018, which after the expiry of 30 days grace period. Hence, this Respondent could not renew the policy. On 5-July-2018, this Respondent had intimated the South Indian Bank that the policy of the complainant cannot be renewed as 30 days grace period has expired. This Respondent had also sought for their confirmation to refund, to which there was no communication from Banks side. It is submitted that on 15th July 2020 South Indian Bank forwarded mail asking for policy copy, to which we had replied that, this insurance company had already informed bank on 5th July 2018 that the policy will not be renewed as the premium was received after 30 days of grace period. After this communication was done with the bank, Bank informed Insurance Company to refund the premium and the account details of the customer was received from the bank only on 17-July-2020 and on that basis this respondent initiated the process for refund immediately and the premium was refunded on 27-Jul-2020. Hence it is humbly submitted that there was no delay from the part of this Respondent in making the refund. This Respondent humbly submits that the complainant has approached this Hon’ble Forum with the complaint of non-renewal of policy for the year 2018-2019 after 3 years from the cause of action. This Respondent was not given any intimation directly by the complainant seeking renewal. The Complainant in spite of being aware that the premium is not deducted in the 2nd week of March, had not approached the respondent seeking renewal at any time during the past 3 years. There is no deficiency of service or unfair trade practice on the part of the Insurance Company. Hence the Complaint is liable to be dismissed at the outset for want of cause of action.

Insurance Policy is a contract and both the parties are under obligation to obey/fulfil all the terms and conditions of the same in the strict sense of the words written therein. As the terms and conditions of the Policy are sacrosanct, the claim arrived is also processed within the precincts of the Policy only. That, this Opposite Party humbly begs to reserve its rights of amendment of the present Written Version on revelation of new facts and circumstances for facilitating justice in the present case. 3. I heard the Complainant and the Respondent Insurer. The Complainant submitted that she was having a Group insurance policy which was going smoothly for almost 10 years with the Chola MS insurers till March 2017, with the premium being auto deducted from her South Indian Bank Account, and auto renewed accordingly. The South Indian Bank changed the Insurance provider from Chola MS to Bajaj allianz in April 2017. For the year 2018, the complainant has not received any policy yet. The premium was auto deducted from her Bank account in the second week of March every year, but this didn’t happen in 2019 and so her health insurance stays cancelled. No reminders / communications were made from the Bank or insurance provider regarding this. It is submitted that the complainant is a 70 year old widow who lost the health insurance cover/benefit which was continuing with Chola MS for 10 years without any claim. The Respondent Insurer submitted that the policy was issued to Mr. Kuriakose K I as the insured on the basis of the information given by the South Indian Bank. The premium was received after 88 days from the expiry of the policy i.e. only on 21-June-2018, which was after the expiry of 30 days grace period. Hence, the respondent insurer could not renew the policy. On 5-July-2018, the respondent insurer intimated the South Indian Bank that the policy of the complainant cannot be renewed as 30 days grace period has expired. The respondent had also sought for their confirmation to refund, to which there was no communication from Banks side. 4. On hearing both the parties, it is found that the complainant was covered under Group Health Insurance Policy for almost 10 years with the Chola MS till March 2017, with the premium being auto deducted from her South Indian Bank S B Account, and auto renewed. But the Bank changed the Insurance provider from Chola MS to Bajaj allianz in April 2017. There was error in the name of her husband and also difference in their age. The premium amount of Rs.5922/- was deducted twice on 3rd and 13th of March 2017 for the year 2017-18 health cover. The provider name was also different in the policy. For the year 2018, the complainant has not received any policy. There was no auto debit of premium for the year 2019 and her policy got cancelled. She had represented, but there was no reply from Bank or the insurer. The respondent insurer is not deducting any premium amount from the account of the complainant. The premium is debited by the bank and thereafter it is paid to the insurer. The bank had paid the premium only on June whereas the policy had to be renewed in March. The insurer had already informed bank on 5th July 2018 that the policy will not be renewed as the premium was received after 30 days of grace period. After this communication was done with the bank, the bank informed Insurance Company to refund the premium and the account details of the customer was received from the bank only on 17-July-2020 and on that basis the respondent refunded the premium on 27-Jul-2020. The complainant has approached this Forum with the complaint of non-renewal of policy for the year 2018-2019 after 3 years. It is found that the complainant should have approached the Bank and get her policy renewed in time. The respondent insurer cannot renew a policy for which premium was received after a delay of 88 days. The complainant alleged that neither the Bank nor the respondent insurer informed her about renewing the policy. The policy was given to the customers of South Indian Bank. Hence it was the duty of the Bank to inform the customer about the change of the provider and about the renewal date of the policy. Hence the respondent insurer is not guilty of what happened in this case. The decision of the respondent insurer is justifiable and hence I do not want to interfere in to their decision.


Dated this the 31st day of August 2021.

Sd/-

(POONAM BODRA)

INSURANCE OMBUDSMAN

AWARD NO. IO/KOC/A/HI/0233/2021-2022






INSURANCE OMBUDSMAN, KOCHI



: Mr. Sudheer K K

House No. 06/694, Kochi 2 Ernakulam,

Pin 682002

2. Policy Number

: 2817/56268900/00/000


: Mr. Koya K


: Universal Sompo Gen. Insu. Co. Ltd.


: 02.06.2021




: --

8. Date of hearing

: 10.08.2021



: Mr. Sudheer K K (Online)

b) For the Insurer : Dr. Ahammed Ali (Online)

AWARD


complaint is regarding rejection of mediclaim. The complainant, Mr. Sudheer K K is the policyholder.


The Complainant stated that he is a policy holder of Universal Sompo General Insurance company since 25/06/2016. His

family consisting of 6 members including father and mother and paying an annual premium of Rs.4576/-. No ID proofs

were required at the time of joining the scheme. No awareness were given regarding the age. His father Koya was

hospitalized on 23/11/2020 and passed away on 01/12/2020. Now it has been 4 months that they had applied for a

claim and it is been rejected by the reason of age.

2. The Respondent Insurer entered appearance and filed a self contained note. It is submitted that that the Insuredobtained“IOB health Care Policy” which covers the period from13/06/2020 to12/06/2021. Copy of policy is annexed and marked as (“Annexure 1”).The policy wordings along with along with the applicable terms and conditions were sent to the Insured.Copy of Policy wordings is annexed and marked as(“Annexure 2”). It is humbly stated that MrKOYA Kwas hospitalized for the period from 23/11/2020 to 01/10/2020 atLISIE HOSPITAL with ailment of Acute atypical viral. Copy of the discharge summary is annexed and marked as (“Annexure 3”) It is stated that as per provided documents,the insured diagnosed with respiratory failure, acute renal failure, neuroendocrine tumour with liver metastasis, COPD Acute exacerbation, Type 2 DM, Systemic hypertension and dyslipidemia. The insured developed hypotension and started on inotropic supports. On 1/12/2020 the insured becameunresponsive and declared expired at 2:25 p.m.The insured had not disclosed detailed past medical history to us in the proposal form on policy inception date. Also, no documents submitted vide multiple reminders. The insured had multiple comorbidities which were not declared to us. Also, DOB as per Aadhar card is 10/05/1945 but, declared DOB to us 3/1/1953. Difference in age observed for 8 years. The claim stands repudiated under non-disclosure of material facts.The proposal form and medical documents are annexed and marked as (“Annexure 4”) The claim of the insured was repudiated vide our letter dated 11/02/2021.Copy of the repudiation letter is annexed and marked as (“Annexure 5”) Exclusions:

It is pertinent to mention at this stage that the policy of insurance is governed by the principles of utmost good faith. A proposer who seeks to obtain a policy of insurance is duty bound to disclose all material facts bearing upon the issue as to whether the insurer would consider it appropriate to assume the risk which is proposed. It is with this principle in view that the proposal form requires a specific disclosure of preexisting ailments, so as to enable the insurer to arrive at a considered decision based on the actuarial risk. In Life Insurance Corporation of India Vs Asha Goel, the apex court has held: “12… The contracts of Insurance including the contract of life assurance are contracts uberrima fides and every fact of material (sic material fact) must be disclosed, otherwise, there is a good ground for rescission of the contract. The duty to disclose material facts continues right up to the conclusion of the contract and also implies any material alteration in the character of risk which may take place between the proposal and its acceptance. If

there is any misstatements or suppression of material facts, the policy can be called into question. For determination of the question whether there has been suppression of any material facts it may be necessary to also examine whether the suppression relates to a fact which is in the exclusive knowledge of the person intending to take the policy and it could not be ascertained by reasonable enquiry by a prudent person”

The said fact has been reiterated in the Judgments in P C Chackovs Chairman, Life Insurance Corporation of India and Satwant Kaur Sandhuvs New India Assurance Co. Limited. In Satwant Kaur Sandhuvs New India Assurance Co. Limited, this court has held “25. The upshot of the entire discussion is that in a contract of insurance, any fact which would influence the mind of a prudent insurer in deciding whether to accept or not to accept the risk is a “material fact”. If the proposer has knowledge of such fact, he is obliged to disclose it particularly while answering questions in the proposal form. Needless to emphasise that any inaccurate answer will entitle the insurer to repudiate his liability because there is clear presumption that any information sought for in the proposal form is material for the purpose of entering into a contract of insurance.”

The aforesaid views has been elaborately discussed vide Judgment dated October 9, 2020 in a three judge bench of the Hon’ble Supreme Court of India in the case of Branch Manager, Bajaj Allainz Life Insurance Company Ltd and Others VsDalbir Kaur wherein the apex court affirmed the repudiation of a claim on account of non-disclosure of preexisting disease. Copy of Apex Court Judgment dated October 9, 2020 is annexed and marked as (“Annexure 6”). Therefore it is humbly stated that the claim has been rightly rejected as per the policy terms & conditions. 3. I heard the Complainant and the Respondent Insurer. The Complainant submitted that his family including his father

and mother covered under IOB health care policy for a um insured of Rs.1,00,000/-. No ID proofs were asked by the

insurance company at the time of submission of proposal form. His father was hospitalized for respiratory failure and

acute renal failure and he is no more now. The reimbursement claim for the hospitalization was repudiated by the

respondent insurance company stating the reason of discrepancy in date of birth when compared with the Adhar card.

The Respondent Insurer submitted that the patient Mr.Koya was hospitalized for the period from 23/11/2020 to

01/12/2020 at Lisie Hospital. The complainant insured submitted the proposal for insurance with date of birth of his

father as 03/01/1953, but the actual date of birth of his father as per Adhar Card is 10/05/1945. This is misrepresentation

of material fact. Hence the claim is repudiated for the reason of misrepresentation & non disclosure of material facts.

4. The non-disclosure of material fact or misrepresentation shall make the insurance cover void ab initio. As per Clause

vii-ii of the insurance policy – The company may cancel the policy at any time on grounds of misrepresentation, non-

disclosure of material facts, fraud by the insured person. Considering these circumstances, facts and evidences, the

decision taken by the insurer to repudiate the claim is justifiable. Since there was non-disclosure of material facts on

part of the complainant, hence I do not find any reason to interfere with the decision of the Insurance Company in

repudiating the claim.


Dated this the 31st day of August 2021

Sd/-

(POONAM BODRA)

INSURANCE OMBUDSMAN



(UNDER RULE NO. 13 1(c) READ WITH RULE 14 OF







: Mrs. Vimala Kumari T P

Girija Bhavan PMRA No 5 Muttada

Trivandrum 695025

2. Policy Number

: EA00602565


: Mrs. Vimala Kumari T P


: HDFC ERGO General Insurance

Company Ltd.


: 11.06.2021


: Revival of policy


: --

8. Date of hearing

: 03.08.2021


a) For the Complainant : Mrs. Vimala Kumari T P (Online)

b) For the Insurer : Mr. Aneesh Bhaskaran (Online)

AWARD

This is a complaint filed under Rule 13 1(c) read along with Rule 14 of the Insurance Ombudsman Rules, 2017. The

complaint is regarding revival of policy. The complainant, Mrs. Vimala Kumari T P is the policyholder.


he Complainant stated that she and her husband were maintaining a policy since 02.03.2017. The premium amount paid

was Rs.13,471/-. Since the complainant did not have an email address, the bank`s email address was provided(IOB –

Peroorkada). Without her knowledge, the insurance policy was transferred from the Apollo Munich to HDFC Ergo.

Therefore the complainant was unaware of any increase in the premium. On 9.3.21, as usual, she remitted the premium

amount at the IOB, Peroorkada Br., Trivandrum. But only when the bank informed the complainant about the lapse of

the policy , she could find out there was a hike in the premium. A complaint was lodged with the HDFC Grievance Cell

on 11.5.21. Since the reply from them was not satisfactory, a complaint was registered in the IRDA portal. A reply received

from them stated that they had informed the details, on 19.1.21 & 29.12.21, through the bank email as well as through

the complainant`s mobile no. 8606573014 . The complainant further stated that neither the bank informed the details

nor the sms on 28.12.20 was not checked as they were aged. The complainant prayed for the reviving the policy.

2. The Respondent Insurer entered appearance and filed a self contained note. It is submitted that the Insured was issued

a Group policy, Easy Health Group Insurance vide Group Policy No 2999 2037 2844 9100000, Group Policy Holder being

Indian Overseas Bank. The Policy issuance date was 06/Nov/2020. Ther policy period was 02/Mar/2020 to 01/Mar/2021,

Family Floater. The Member was first covered on 02/Mar/2017. Member,68 yrs., and his wife 64 yrs., were covered for

a SI for Rs. 5,00,000/-.

It is the version of the Complainant, that they were not aware of the renewal of the Health Insurance and the change in

the premium amount. The Complainant states that the insured being aged and not tech savvy, they were oblivious of

any change in the Company and the premium amount. If it is taken for an argument that the Insured were not tech savvy

as per the averment in the complaint, this Insurer had send multiple communications calling the attention of the Insured

for renewal of the policy via email on 29/12/2020, 19/01/2021 & 24/5/2021 and also an SMS was sent on 28/12/2020,

to the number registered and the address as per the policy. The last communication letter was dated 26/5/2021.

The Insured or the Complainant cannot vehemently deny that, they were not aware when their Insurance was due for

renewal. Further, this Insurer via Print / Electronic Media and by various other modes has been airing advertisements to

educate our customer and the public at large about the merger of Erstwhile Apollo Munich with HDFC ERGO GIC. In the

current world of Electronic media, it is difficult to believe that the Insured had not heard about the Merger. We further

wish to submit that, regardless of sharing communication by various modes by this Insurer, the Insured for reason best

known had not chosen to renew the policy and is now making evasive reasons to vindicate their dereliction in not

initiating the renewal.

The policy was not renewed only due the lapse on the part of the Insured for which this Insurer cannot be held liable. All

the averments about age, not being tech savvy, COVID, insufficient fund etc., are only a self-serving version and are not

admitted. There was no deliberate attempt on the part of this respondent to arbitrarily deny the renewal of the policy.

It is therefore humbly prayed that the Honourable Ombudsman may be pleased to dismiss the present complaint and

exonerate this Respondent Insurer from any liability in respect to the subject claim.

3. I heard the Complainant and the Respondent Insurer. The Complainant submitted that she and her spouse were

maintaining a health policy with Apollo Munich through the IOB, Peroorkada, Trivandrum. The renewal premium though

was remitted on 9.3.21 through the said bank, they were later informed by the bank that the policy got lapsed. The

complainant claimed that she was neither informed of the transfer of the policy from the Apollo Munich to HDFC Ergo

nor the premium increase. Since they were not tech savy and were not having an email address, the bank`s email id was

given to the respondent insurer. But neither the bank nor the respondent insurer had informed them about the premium

details. The sms send by the respondent insurer was not checked as they do not know to check. The complainant pleaded

for the reinstatement of the policy. The respondent insurer submitted that the policy was not renewed only because of

the lapse on the part of the Insured for which the Insurer cannot be held liable. All the averments about age, not being

tech savvy, COVID, insufficient funds etc., are only a self-serving version and are not admitted. There was no deliberate

attempt on the part of the respondent insurer to arbitrarily deny the renewal of the policy. The Insurer had send variuos

communications to the Insured for renewing policy via email on 29/12/2020, 19/01/2021 & 24/5/2021 and SMS on

28/12/2020, to the number registered and the address as per the policy and the last communication letter was send on

26/5/2021. The respondent insurer prayed for dismissing the complaint.

4. I heard the complainant and the respondent insurer and had gone through the records submitted by them.

In this case the policy renewal was lapsed due to nonpayment of precise premium. On analyzing the hearing and the

records, I find that ,both the insured are senior citizens . They had provided their bank`s email address to the respondent

insurer for communication purposes as they don`t have an email address, which indicated that they are not accustomed

to such communication facility . Simillarly for Sms also. Further, they had remitted the then existed premium on 9.3.21,

which signified their intention that they wanted to renew the policy.

Taking into cognizance the above said points and their age factor, the respondent insurer is directed to renew the policy

with continuity and the enhanced premium with applicable interest for delayed payment.

The respondent insurer submitted that Total applicable premium for the Insured Mrs. Vimalakumari TP (64 yrs) & Mr.

K. Vijayakumar (68 yrs.) with Service Tax is Rs. 21,614/- .

In the result, an award is passed, directing the Respondent Insurer to renew the policy with continuity and the applicable

premium of Rs.21,614/- , within the period mentioned hereunder. No cost.

As prescribed in Rule 17(6) of Insurance Ombudsman Rules, 2017, the Insurer shall comply with the award within 30 days

of receipt of the award and intimate compliance of the same to the Ombudsman.


Sd/-

(POONAM BODRA)

INSURANCE OMBUDSMAN










: Mr. Prasannakumar K

(Rtd. Manager, Milma, Kollam),

Sreeragam, Olayil, Thevally, Kollam -

691009

2. Policy Number

: 4101190700000075-001


: Mr. Prasannakumar K


: SBI General Insurance Co. Ltd


: 21.06.2021




: --

8. Date of hearing

: 11.08.2021



: Mr. Prasannakumar K (Online)

b) For the Insurer : Ms. Akamsha Gehlot (Online)

AWARD


complaint is regarding rejection of mediclaim. The complainant, Mr. Prasannakumar K is the policyholder.


The Complainant stated that he is a retired Dairy Manager of the Kollam Diary and is a beneficiary of the group medical

insurance policy issued by the respondent insurer in favor of the Managing Director , TRCMPU Ltd, Trivandtum. The

complainant underwent treatment for Gall Bladder stone at PRS Hospital, Trivandrum and had lodged a claim under the

said policy for Rs.1,61,791/-. The claim was settled for Rs.81,959/-. The remaining allowed by the Kollam Diary

amounting to Rs.75,000/- from the buffer fund is not paid till date. An amount of Rs.1,20,000/- was left in the Buffer

Fund for the year 19/20 at the time of lodging the claim. The respondent insurer and the intermediary are legally bound

to pay Rs.75,000/-, as per the terms of the aforesaid Group Medical insurance Policy No. 4101190700000075-00.

2.The Respondent Insurer entered appearance and filed a self contained note. It is submitted that a Group Health

Insurance Policy Bearing Policy No. 4101190700000075-00 was issued by SBI General in the name of 516 employees of

“Thiruvananthapuram Regional Cooperative Milk Producers Union Limited” which included the Complainant i.e.

“Prasannakumar K.” which was effective from 02/07/2019 to midnight 01/07/2020, subject to its terms and conditions

and any claim is admissible in adherence to the same (hereinafter referred to as the “said Policy”). The insured , was

hospitalized in “PRS Hospital” from 13/06/2020 to 20/06/2020 for the treatment of calculus cholecystitis,

choledocholithiasis and underwent surgical management for the same. Subsequently, a reimbursement claim bearing

no. HI-SBI-001079244(0) / SBIG Claim no. 202220044193-01 was registered with SBI General through “HealthIndia

Insurance TPA Services Pvt. Ltd.” The claim file of the Complainant was assessed by appointed TPA to complete the

process of evaluation of authenticity and eligibility of the aforesaid reimbursement claim. Accordingly, an amount of Rs.

74,784/- was found to be inadmissible under the subject policy terms and conditions, out of the total claimed amount of

Rs 1,56,743/-. The deducted amount relates to, expenses on Consumables, medicines and instruments, Assistant doctor

and dietician charges over and above the sum insured for the insured person/Complainant as mentioned in the Schedule

of the policy. based on the TPA’s final assessment vis-a-vis Policy terms and conditions, liability of the Company was

established to the tune of Rs. 81,959/- (Rupees Eighty-one thousand, Nine hundred and Fifty-nine only) against total

claimed amount of Rs. 1,56,743/- (Rupees One lakh, Fifty-six thousand, Seven hundred and forty-three only). That

accordingly Rs. 81,959/- was settled, through NEFT payment dated 09/10/2020 vide UTR no. SBIN320283579192. It is

pertinent to note that the “Corporate buffer” is a common pool of coverage maintained at an organization level. This

can be availed in case of any medical emergency falling under allowed illnesses, after exhaustion of individual employee's

Family Floater coverage. Further, we would like to mention here that the subject policy of the insured/ Complainant

provides for the provision of Corporate Buffer, the condition of which states that: “Corporate Buffer Annual Limit: 5 lacs

subject to restriction of max Per family limit: upto floater SI. Corporate buffer cannot be utilised for maternity claims and

non-allopathic treatment. Utilization of Corporate buffer limit shall be allowed after exhaustion of base Sum Insured.”

The sum insured in the present case has been exhausted, however, no approval for buffer release for this employee has

been received by SBIG. The Corporate buffer can be released only after Company receives approval from the HR of the

said Corporate, that is, “Thiruvananthapuram Regional Cooperative Milk Producers Union Limited” in this case. Hence,

the insured/Complainant ought to approach the concerned in HR department of his office and provide us with necessary

approvals for accessing his organisational Corporate buffer fund. The insurer had not received any representation from

the Complainant referring its grievances to GRC (Grievance Redressal Committee). In the view of the abovementioned

facts and circumstances, there is no error apparent, which calls for the interference of the Ld. Ombudsman and the

present Complaint is liable to be dismissed on account of being misconceived and premature.

3. I heard the Complainant and the Respondent Insurer. The Complainant submitted that he complainant retired Diary

Manager, underwent treatment for Gall Bladder stone at PRS Hospital, Trivandrum. Out of claimed amount of

Rs.1,61,791/-,under the group medical insurance policy issued by the respondent insurer in favor of the Managing

Director , TRCMPU Ltd, Trivandrum, the claim was settled only for Rs.81,959/-. The remaining allowed by the Kollam

Diary amounting to Rs.75,000/- from the buffer fund is not paid till date. He had taken up the matter with the

Intermediary, Securus Insurance Brokers India Pvt. Ltd.

An amount of Rs.1,20,000/- was left in the Buffer Fund for the year 19/20 at the time of lodging the claim . The

respondent insurer is legally bound to pay the balance amount of Rs.75,000/-, as per the terms of the aforesaid Group

Medical insurance Policy .

The Respondent Insurer submitted that the sum insured in the present case had been exhausted and no approval for

the buffer release for the complainant was received by the respondent insurer. The Corporate buffer can be released

only after the respondent insurer receives approval from the HR of the said Corporate- Thiruvananthapuram Regional

Cooperative Milk Producers Union Limited . Hence, the Complainant ought to approach the HR department of his office

and provide us with necessary approval for accessing his organisational Corporate buffer fund. Furthermore, the insurer

had not received any representation from the Complainant referring its grievances to GRC (Grievance Redressal

Committee). The Complaint is liable to be dismissed .

4. I heard the complainant and the respondent insurer and had gone through the records submitted.

1.The complainant argued that his claim of Rs.1,61,791/-, for gall bladder treatment was settled only Rs.81,959/-. The

balance claim amounting to Rs.75,000/-, allowed by the Kollam Diary from the buffer fund is not paid till date. The

respondent insurer and the intermediary are legally bound to pay the said remaining claim amount of Rs.75,000/-, as

per the terms of the aforesaid Group Health Insurance Policy.

2. The sum insured in the present case had been exhausted and approval for the buffer release for the complainant was

not received by the respondent insurer. The Corporate buffer can be released only after the respondent insurer receives

approval from the HR of the said Corporate- Thiruvananthapuram Regional Cooperative Milk Producers Union Limited .

On analyzing the records and the hearing, I find that the arguments put forth by the Respondant insurer are tenable. I

therefore do not want to interfere in the decision of the respondent insurer in denying the claim



Sd/-

(POONAM BODRA)

INSURANCE OMBUDSMAN










: Mr. Venu Nair N

Geethanjali Kizhakedath House

Thadampattuthazham P O Karaparamba

Kozhikode Kerala 673010

2. Policy Number

: OG-21-1603-6021-00000810


: Mr. Venu Nair N


: Bajaj Allianz General Insc Co. Ltd.,


: 14.06.2021




: --

8. Date of hearing

: 13.08.2021



: Mr. Venu Nair N (Online)

b) For the Insurer : Ms. Reshma, Mr. Ravindra Shinde (Online)

AWARD


complaint is Rejection of mediclaim. The complainant, Mr. Venu Nair N is the policyholder.


The Complainant submitted that he had been holding a mediclaim insurance covered by Syndicate Bank through United

India Insurance Company limited from 15.03.2012 covering himself and his spouse. The policy was continuously in force

without any break as it was renewed periodically. As his policy was due for renewal on 14.03.2021, he approached the

Bank for renewal in the month of January 2021. The Bank informed him that their agreement with United India was

terminated in view of the merger of the Bank with Canara Bank and they persuaded him to renew the policy –port the

policy to Bajaj Alliance General Insurance Co with whom they had an agreement to cover their customers for health

insurance. The complainant insisted that by renewing with the respondent insurer he should not lose any benefit of

continuous coverage and it should be a continuous policy without break. The Bank advised him to renew the policy with

the respondent insurer and introduced him to an employee of the insurer and he also assured that he would not have

any problem by joining the respondent insurer. He again reminded that if they had any problem in giving the continuity,

he could try to renew the policy with United India, the existing insurer as there was around 2 months to expire the policy.

Both the Bank and the respondent insurer’s employee assured him continuous insurance cover and they promised that

his interest will be protected. Believing the assurances of the Bank and the insurer, he signed on the proposal form on

good faith. In January as the Bajaj employee informed that it was a formality and as the cover is continuous they will fill

the forms and submit to the company and the policy was issued on 20th February 2021 charging Rs.24802/- as premium

ie almost three times of the previous policy. The premium for the previous policy was only Rs.9360/- with United India.

The present policy with the respondent insurer mentions that the policy is continuous for 7 years from 15.03.2014 even

though it is from15.02.2012. even today the complainant has not received the copy of the proposal form which he is

entitled to get along with the policy. Non submission of copy of proposal along with policy as per IRDA guidelines is a

clear deficiency of service on the part of the insurer.

When he questioned about the steep increase in premium (Rs.34802/- from Rs.9360/-) for a sum insured of Rs.4 lakh,

the agent informed that high premium is charged to give continuity of the cover and all benefits under the existing policy.

The agent advised him to take another policy for a sum of Rs.5 lacs for enhancing the sum insured as he suggested that

Rs.4 lacs is quite insufficient nowadays. He agreed for the same and took new policy for 5 lacs additional sum insured for

himself and for his wife for which only Rs.7167/- each was charged. Premium for Rs.4 lacs is Rs.24802/- and premium for

a sum of Rs.5 lacs is Rs.7167/-. The comparison of this differential rating of these two policies would reveal that in spite

of paying heavy premium for continuity of cover, he was meted out with a raw deal by the insurance Co. Even after

paying 3 times premium for continuous cover for Rs.4 lacs, his claim was rejected which is an unfair trade practice and

amounts to cheating.

On 05.04.2021, he was admitted to Meitra Hospital, Kozhikkode and had to undergo an angiogram followed by an

angioplasty and was discharged on 07.02.2021. As he informed the insurer through the agent he informed that there is

no cashless tie up with this hospital and advised him to remit the hospital bills and claim reimbursement. With much

difficulty, he had to organize the required fund to pay the hospital bills. He lodged the claim for reimbursement for

Rs.1,68,389/- and to his utter dismay, he got a message that his claim is inadmissible and to contact a toll free number.

On contacting the toll free number he was told that his claim is rejected as he has not disclosed some facts on the

proposal form. It is hereby denied all allegations of non-disclosure and he reiterate that he has not suppressed any facts

and there is no need for him to suppress any fact as his policy is continuous from 15.03.2012. He had insurance coverage

even before that as he had been covered by his employer, M/s Mathrubhoomi Newspaper, a leading newspaper in Kerala

under their group insurance policy. After his retirement he took the policy from United India through Syndicate Bank.

Though he had continuous coverage right from his Mathrubhoomi days, fortunately he had no claims and his first claim

is rejected by the respondent insurer for no fault of him on flimsy grounds. The only mistake did by him is that he believed

the respondent insurer who persuaded him to shift the insurance Co. The previous policy which shows the continuous

cover from 15.03.2012 is enclosed. For so many years , right from his Mathrubhoomi days he has been paying premium

continuously and this blatant denial of the genuine claim at a time o when he was in real distress has shaken his

confidence in the insurance system.

On 29.5.2021, he received a letter from the respondent insurer intimating that his claim is rejected on the following

grounds.

“The disease for which the claim has been raised is preexisting and the same has not been disclosed in the proposal

form”.

On 30th May, he sent a complaint to the Grievance department of the respondent insurer, intimating that their denial

of claim based on flimsy ground is illegal and to reconsider the claim to which they replied that they stick to their stand.

Both the complaint and reply is attached for reference. On 03.06.2021, the respondent insurer sent a mail in reply to his

grievance mail threatening that his subject policy could be cancelled as the disease is a preexisting one to Bajaj policy

though he has a continuous cover since there is non-disclosure. He had replied stating that he has not suppressed any

material fact and there is no need for him to do so as his policy was continuous from 2012 onwards without any break.

He had requested them not to cancel his policy as it would be illegal, arbitrary, unjust and unfair and he will be left with

no insurance during his lifetime as no insurer would insure him at this age. Also submitted that he should not be punished

for believing this respondent insurer while porting his policy. While taking his signed proposal form, the agent advised

him that he will fill it up and submit the same to the insurer and it is only a formality and there will not be any problem.

In view of the continuity of the policy.

The allegation of non-disclosure is baseless and without any substance as there was no manifestation of any heart disease

at the time of renewing insurance in the month of January which was diagnosed only on 05.04.2021 through an

angiogram. If the allegation is based on the consultation he had on 18th January, it is submitted that it was an OP

treatment for wheezing which was not at all serious to mention. In view of the continuity of the policy he has no need

to suppress a preexisting condition. The present policy was issued from 20.02.2021 commencing the risk from 15.03.2021

and the disease was diagnosed only on 05.04.2021 through angiogram. He had given the Op prescriptions to the agent

to submit along with the claim papers. If he had any intention to suppress, he would not have given this and it shows his

good faith and good intention. There is no suppression of a preexisting disease even for argument sake. The column for

preexisting condition is filled with a line by the agent and the company has accepted the same. If it is material the

company should have asked more clarification before accepting the risk with this incomplete proposal. Hence this

allegation is raised now to deny the benefits illegally under the policy.

The denial of his legitimate claim on the grounds of preexisting condition, under a continuous policy from 15.03.2012 is

frivolous, arbitrary, illegal and against IRDA guidelines on porting of Health insurance policies. It is requested to direct

the respondent insurer to pay Rs.1,68,389/- with 12 % interest and cost. Also direct the respondent insurer not to cancel

his policy, which is valid and continuous from 15.03.2012 and such an act would be inhuman and unjust as it would cause

repairable loss to the insured as he would be left with no insurance during his lifetime as insurers are not entertaining

policies for aged people.

2. The Respondent Insurer entered appearance and filed a self-contained note. It is submitted that all averments in the

complaint except those that are specifically admitted or dealt with hereunder are denied by the respondent.

The averment in the complaint about the issuance of policy to the petitioner is admitted. The Policy number: OG-21-

1603-6021- 00000812 MEDICLAIM INSURANCE POLICY-CANARA BANK for the period of 15-MAR-2021 to 14-MAR-2022

in favour of the petitioner was issued under certain terms, conditions and limitation thereof.

There is no deficiency of service or unfair trade practice on the part of the Insurance Company. Hence the Complaint is

liable to be dismissed at the outset for want of cause of action. . Insurance Policy is a contract and both the parties are

under obligation to obey/fulfill all the terms and conditions of the same in the strict sense of the words written therein.

As the terms and conditions of the Policy are sacrosanct, the claim arrived is also processed within the precincts of the

Policy only.

Insured Mr. VENU NAIR N was holding SYND AROGYA (Group Health Insurance Scheme : Syndicate Bank) with United

India Insurance Co. Ltd from 5-MAR-2014 to 14-MAR-2021 with Sum insured of 4 Lakhs and Continuous renewal,

Agreement of Syndicate Bank was completed and Canara bank during bank merger as per RBI guidelines already Canara

bank had tied up with this Respondent and hence the continuity of their existing policy with fresh portability and proposal

form was duly filled and signed. This Respondent Insurance company have issued Policy on 20-FEB-2021 - Plan Chosen:

Group Mediclaim Insurance - Canara Bank (Previously Syndicate Bank) with special continuity conditions – “IT IS HEREBY

AGREED AND UNDERSTOOD THAT THE MEDICLAIM INSURANCE POLICY IS ISSUED WITH PORTABILITY BENEFIT FROM

MEDICLAIM POLICY OF UNITED INDIA INSURANCE CO. LTD. AND CONTINUITY IS EXTENDED FROM 15- 03-2014. THE

CONTINUITY FOR CONTINUITY FOR 7 YEARS IS EXTENDED ON SUM INSURED OF RS. 400000 FOR VENU NAIR N, GEETHA

N. ALL OTHER TERMS, CONDITIONS, COVERAGE AND EXCLUSIONS OF THE POLICY REMAIN UNALTERED, ALL WAITING

PERIODS APPLY AFRESH ON ENHANCED SUM INSURED. ANY DISEASE/INJURY CONTRACTED DURINGBREAKIN PERIOD

WILL NOT BE PAYABLE.”

As per proposal form and portability form the complainant/insured have not declared any of the ailments with regards

to SMOKING (question 21), Chest pain/Angina (question 23), Details of illness if any (question 3 24, 25), As per Portability

form Declaration undersigned as “I hereby declare that the information given in this application is true and correct to

best of my knowledge and belief. In Case of any information given in this application proves to be false or incorrect I Shall

be responsible for the consequences” with duly signed on 18-Feb-2021.

The claim documents submitted by the complainant shows that the complainant was hospitalized for the treatment of

Exertional Angina Class II, Coronary artery disease and is claiming for expenses incurred of INR. 162832/-. The policy

issued by this Respondent incepts on 15- Mar-2021. The Discharge Summary issued from Meitra Hospital shows that the

complainant was admitted on 5-4-2021 and was discharged on 7-4-21 following coronary angiography. The Discharge

Summary also mentions that the complainant is suffering from Exertional Angina since 6 months, which is pre-existing

to the policy of this Respondent and has not been disclosed in the proposal form while portability.

As per the investigation and consultation carried out in Nirmala hospital on 22 Jan 2021 that before policy inception

date with respondent, Dr Nanda Kumar S have treated insured for Exertional angina and was on continuous treatment

and still such grievous ailments nature is not disclosed on proposal form while portability, and as per clean proposal form

and no any declaration duly signed we have issued the policy without pre policy check-up as per the principle of utmost

good faith.

lause C1 of the policy terms and conditions stipulates

What we will not pay (Exclusions) under this policy? We shall not be liable to make any payment for any claim directly or

indirectly caused by, based on, arising out of or attributable to any of the following:

Benefits will not be available for Any Pre-existing condition, ailment or injury, until 36 months of continuous coverage

have elapsed, after the date of inception of the first Mediclaim Insurance Policy provided the pre-existing disease /

ailment / injury is disclosed on the proposal form. The above exclusion 1 shall cease to apply if You have maintained a

Mediclaim Insurance Policy with Us for a continuous period of a full 36 months without break from the date of Your first

Mediclaim Insurance Policy.In case of enhancement of Sum Insured, this exclusion shall apply afresh only to the extent

of the amount by which the limit of indemnity has been increased (i.e. enhanced Sum Insured) and if the policy is a

renewal of Mediclaim Insurance Policy.

Clause B 16 of the policy terms and conditions states that Disclosure to information norm The Policy shall be void and all

premium paid hereon shall be forfeited to the Company, in the event of misrepresentation, mis-description or non-

disclosure of any material fact. The complainant has stated in the Proposal Form that he is not suffering from any pre-

existing ailments. This amounts to nondisclosure of material facts. As per the said terms and conditions of impugned

insurance contract entered between the Parties, it was mandatory for the complainant to not conceal anything. Thereby

the declaration given for taking the present indemnification cover was found to be false. Hence, the respondent had

cancelled the policy issued to the complainant as he has breached the principle of utmost good faith and he is not entitled

to any benefit under the present Insurance Cover and non-refund of any pro-rata premium as claim was made on the

said policy

In view of Portability guidelines stated by IRDAI - Ref: IRDAI/HLT/RE G/CIR/177/09/2019 Dated-27-Sept 2019.

In view of no revert on Non-disclosure notice we have cancelled the policy. As if the ailment was disclosed to us as per

the principle of Utmost good faith before portability we would have not ported the policy with us.

Thus, under these facts and circumstances, this Respondent says and submits that the claim under the policy was rightly

denied as per terms and condition of the policy and as per guidelines of IRDAI and all the contents of complaint are

denied by this respondent for want of sufficient evidence.

The allegation of the complainant that the employee of this Respondent assured him to merely sign and that they would

fill up the details is without merit. In all cases it is directed that the Proposal For be filled by the customer itself. The

Complainant here was an employee in a reputed organisation and was also a previous policy holder of another policy.

So it cannot be claimed that he was unaware that he himself must have filled up the proposal form. 16. A contract of

insurance is one of utmost good faith. A proposer who seeks to obtain a policy is duty bound to disclose all material facts

bearing upon the issue as to whether the insurer would consider it appropriate to assume the risk which is proposed. It

is with this principle that the proposal form requires specific disclosure of pre-existing ailments so as to enable the insurer

to arrive at a considered decision based on the actuarial risk. The Hon’ble Supreme Court Of India in Reliance Life

Insurance Co Ltd & Anr v. Rekhaben Nareshbhai Rathod Civil Appeal No. 4261/2019 has held that the contention that

the signature of the insured was taken without explaining the details of the terms and conditions cannot be accepted.

The Court relied on the decision of the Division Bench of the Mysore High Court in V K Srinivasa Setty v. Messers Premier

Life and General Insurance Co Ltd wherein it was held that a person who affixes his signature to a proposal which contains

a statement which is not true, cannot ordinarily escape from the consequence arising therefrom by pleading that he

chose to sign the proposal containing such statement without either reading or understanding it. That is because, in

filling up the proposal form, the agent normally, ceases to act as agent of the insurer but becomes the agent of the

insured and no agent can be assumed to have authority from the insurer to write the answers in the proposal form.

The averment of the complainant that there was no manifestation of heart disease at the time of renewing the insurance

in the month of January is false. The Discharge Summary mentions that the complainant is suffering from Exertional

Angina since 6 months. So the complainant cannot claim that there was no non-disclosure of preexisting ailments. It was

for these reasons the claim of the complainant was repudiated. The respondent is not guilty of any deficiency in service

as alleged in the complaint. That, this Opposite Party humbly beg=s to reserve its rights of amendment of the present

Written Version on revelation of new facts and circumstances for facilitating justice in the present case. Therefore, it is

humbly prayed that this Hon’ble Ombudsman may be pleased to accept this self-contained notes and to dismiss the

complaint with the cost to this Respondent.

3. I heard the Complainant and the Respondent Insurer. The Complainant submitted that he had been holding a

mediclaim insurance covered by Syndicate Bank through United India Insurance Company limited from 15.03.2012

covering himself and his spouse. The policy was continuously in force without any break as it was renewed promptly. As

his policy was due for renewal on 14.03.2021, he approached the Bank for renewal in the month of January 2021. The

Bank informed him that their agreement with United India was terminated and they persuaded him to renew the policy

by porting to Bajaj Alliance General Insurance Co, their new insurance provider. Even though he had to pay Rs.24802/-

as premium which was almost three times of the premium of Rs.9360/- with United India, he paid the same. The proposal

was signed on January, the policy was issued on 20th February 2021.On 05.04.2021, he was admitted to Meitra Hospital,

Kozhikkode and had to undergo an angiogram followed by an angioplasty and was discharged on 07.02.2021. The claim

was repudiated by the respondent insurer on the ground that he had not disclosed any of his illness with regards to

Smoking, Chest pain Angina for which he had consulted a Doctor during January. The complainant submitted that he had

no intention to conceal any illness as he was porting his policy which was continuous since 2012. The proposal form was

prepared by the agent of the insurer and the complainant had only signed in it. As there was continuity, he is eligible for

all the benefits he was enjoying with the previous insurer. It was assured orally that the proposal form is only formability

and all the benefits will be available. But the respondent insurer repudiated the claim on non-disclosure of material fact

and also threatened him to cancel the policy. It is submitted that the claim may be paid and direct the respondent insurer

not to cancel his policy.

The Respondent Insurer submitted that as per proposal form and portability form the complainant has not declared any

of the ailments with regards to SMOKING (question 21), Chest pain/Angina (question 23), Details of illness if any (question

3 24, 25), As per Portability form Declaration undersigned as “I hereby declare that the information given in this

application is true and correct to best of my knowledge and belief. In Case of any information given in this application

proves to be false or incorrect I Shall be responsible for the consequences” with duly signed on 18-Feb-2021. The

complainant was hospitalized for the treatment of Exertional Angina Class II, Coronary artery disease and claimed for

expenses incurred of Rs. 162832/-. The policy issued by this Respondent incepts on 15- Mar-2021. The Discharge

Summary issued from Meitra Hospital shows that the complainant was admitted on 5-4-2021 and was discharged on 7-

4-21 following coronary angiography. The Discharge Summary also mentions that the complainant is suffering from

Exertional Angina since 6 months, which is pre-existing to the policy of this Respondent and has not been disclosed in

the proposal form while portability. Benefits will not be available for any Pre-existing condition, ailment or injury, until

36 months of continuous coverage have elapsed, after the date of inception of the first Mediclaim Insurance Policy

provided the pre-existing disease / ailment / injury is disclosed on the proposal form. Hence the claim is not admissible.

4. I heard both the parties and on scrutiny of the documents it is found that in the proposal form is signed by the

complainant, the question regarding presence of ailments is kept blank, just a hyphen is drawn. The complainant

submitted that the proposal form was filled by the agent,. He shouldn’t have allowed any agent to fill in the proposal

form. As per INSURANCE REGULATORY AND DEVELOPMENT AUTHORITY OF INDIA (HEALTH INSURANCE) REGULATIONS,

20161 [Amended upto 19/11/2019] , the policyholder shall fill in the portability form along with proposal form and

submit the same to the insurance company. It is an important document on which a prudent insurer decides whether

to accept the risk and issue the policy. If the preexisting illnesses were declared either the insurer will issue a policy with

loading of premium or will not accept the risk. In such a situation, the complainant could have continued his policy with

the earlier insurer. The respondent insurer issued the policy with utmost good faith, believing that the declarations made

in the proposal form are correct. But when a claim occurred it is found that the complainant was suffering from cardiac

issues from January whereas, the proposal form was signed on 18.feb.2021and the policy commenced on 15 March 2021.

On verification of the document submitted it is revealed that the complainant had consultation and undergone test at

Nirmala Hospital on 22 Jan 2021. The test result shows that he had concentric LVH,Atia mildly dialated, Trivial TR,Sclerotic

Aortic valve. Medical documents from Nirmala Hospital dated 22 Jsnusry 2021 shows that he was prescribed medicines

including Ecosporin,Concor 2.5 each timeHence at the time of signing the proposal form, the complainant was very well

aware that he was suffering from serious heart ailment .The claim was repudiated by the respondent insurer based on

the policy terms and conditions and hence their decision is justifiable. As there is suppression of material fact the policy

becomes null and void. The decision of the respondent insurer to cancel the policy in respect of the complainant under

dispute is justifiable. Hence I do not want to interfere in to the decision of the respondent insurer.


Dated this the 31ST day of August 2021

Sd/-

(POONAM BODRA)

INSURANCE OMBUDSMAN

AWARD NO. IO/KOC/A/HI/0248/2021-2022






INSURANCE OMBUDSMAN, KOCHI



: Mr. V Subhash Chandran

Sree Veedu Mulleppilly Road East

Kadungalloor U C College P O Aluva

683102

2. Policy Number

: 2850/62114629/00/000


: Mr. V Subhash Chandran


: Universal Sompo Gen. Insu. Co. Ltd.


: 09.06.2021




: --

8. Date of hearing

: 10.08.2021



: Mr. V Subhash Chandran (Online

b) For the Insurer : Dr Ahamed (Online)

AWARD

his is a complaint filed under Rule 13 1(b) read along with Rule 14 of the Insurance Ombudsman Rules, 2017. The

complaint is regarding rejection of mediclaim. The complainant, Mr. V Subhash Chandran is the policyholder.


The Complainant stated that he had a problem of speech suddenly on 17/01/2021 at 6.00 pm. He went a local hospital

and consulted a doctor in casualty. He checked his blood pressure and other basis checkups and given some medicines

also advised him to meet a physician next day. He met a physician and he prescribed some medicines after whole

checkup in the same hospital. On 18/01/2021 evening, he suffered the same problem of slurring of speech at around 4

pm and as advised by the physician for taking MRI Scan, they prefer to go to Aster Medicity, Kochi and admitted therein

and discharged on 20/01/2021 evening with some medicines and advised to take the same regularly. The cashless

request sent by Aster Medicity was denied by the respondent insurer on the ground that the patient has HTN since last

two years as mentioned in their ERM or OPD dated 18/01/2021. He took up the matter with CMO of Aster Medicity and

apprised him his insurance company denied his cashless treatment due to the hospital authorities mentioned the history

of HTN wrongly in the EMR/OPD report, whereas he had no such problem of HTN and he is not taking any medicines

regularly for such disease. As request by him hospital issued a letter admitting their mistake of false statement in their

EMR/OPD dated 18/01/2021, which he handed over to the insurance company on 30/01/2021. He mailed all connected

papers to the Grievance cell of Universal Sompo Insurance and after repeated reminders, the insurance company

informed him that his claim is repudiated.

2. The Respondent Insurer entered appearance and filed a self contained note. It is submitted that the complainant

insured obtained online “IOB Health Care Policy” which covers the period from 02/11/2020 to 01/11/2021. The policy

along with the applicable terms and conditions were sent to the insured. The complainant was admitted at Aster DM

Healthcare (P) Ltd with ailment of Acute Stroke. On further scrutiny of documents it is found that the insured has a

history of HTN since 2 years and same was not disclosed during policy inception and is a major non-disclosure so the

claim has been repudiated.

Exclusions:

It is pertinent to mention at this stage that the policy of insurance is governed by the principles of utmost good faith. A proposer who seeks to obtain a policy of insurance is duty bound to disclose all material facts bearing upon the issue as to whether the insurer would consider it appropriate to assume the risk which is proposed. It is with this principle in view that the proposal form requires a specific disclosure of preexisting ailments, so as to enable the insurer to arrive at a considered decision based on the actuarial risk. In Life Insurance Corporation of India Vs Asha Goel, the apex court has held:

“12… The contracts of Insurance including the contract of life assurance are contracts uberrima fides and every fact of material (sic material fact) must be disclosed, otherwise, there is a good ground for rescission of the contract. The duty to disclose material facts continues right up to the conclusion of the contract and also implies any material alteration in the character of risk which may take place between the proposal and its acceptance. If there is any misstatements or suppression of material facts, the policy can be called into question. For determination of the question whether there has been suppression of any material facts it may be necessary to also examine whether the suppression relates to a fact which is in the exclusive knowledge of the person intending to take the policy and it could not be ascertained by reasonable enquiry by a prudent person”

The said fact has been reiterated in the Judgments in P C Chackovs Chairman, Life Insurance Corporation of India and Satwant Kaur Sandhuvs New India Assurance Co. Limited. In Satwant Kaur Sandhuvs New India Assurance Co. Limited, this court has held

“25. The upshot of the entire discussion is that in a contract of insurance, any fact which would influence the mind of a prudent insurer in deciding whether to accept or not to accept the risk is a “material fact”. If the proposer has knowledge of such fact, he is obliged to disclose it particularly while answering questions in the proposal form. Needless to emphasise that any inaccurate answer will entitle the insurer to repudiate his liability because there is clear presumption that any information sought for in the proposal form is material for the purpose of entering into a contract of insurance.”

The aforesaid views has been elaborately discussed vide Judgment dated October 9, 2020 in a three judge bench of the Hon’ble Supreme Court of India in the case of Branch Manager, Bajaj Allainz Life Insurance Company Ltd and Others VsDalbir Kaur wherein the apex court affirmed the repudiation of a claim on account of non-disclosure of preexisting disease. The contract of Insurance is a contract of Utmost Good Faith and any misrepresentation, mis –description makes the contract null and void ab initio.

3. I heard the Complainant and the Respondent Insurer. The Complainant submitted that on routine evaluation at Aster

Medicity on 18/01/2021, his HbA1C was noted high of 10.5% and hence he was started on diabetic management. He

had no previous co-morbid illnesses such as diabetics or hypertension noted before. He was diagnosed with

hypertension and diabetics from only at the time of admission at Aster Medicity hospital. The Respondent Insurer

submitted that the complainant was admitted at Aster DM Healthcare (P) Ltd with ailment of Acute Stroke. On further

scrutiny of documents it is found that the insured has a history of HTN since 2 years and the same was not disclosed

during policy inception and is a major non-disclosure so the claim has been repudiated.

4. After hearing the complainant and respondent Insurer and perusing the exhibits produced before the forum, I find

that the insured patient had the history of HTN, DM and other Co-morbidities, which is not declared at the time of

proposal of this insurance. As per the policy condition the proposer/insured is bound to disclose his pre-existing

condition/diseases while taking the policy. The non-disclosure of material fact or misrepresentation shall make the

insurance cover void ab initio. Considering these circumstances, facts and evidences, the decision taken by the insurer

to repudiate the claim is justifiable. So I do not find any reason to interfere with the decision of the Insurance Company

in repudiating the claim.



Sd/-

(POONAM BODRA)

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, Kolkata (States of West Bengal, Sikkim and Union Territories of Andaman & Nicobar Islands) (UNDERRULENO.16/17OFTHEINSURANCEOMBUDSMANRULES,2017) Ombudsman Name: P.K. RATH CASE OF COMPLAINANT– DR. (MRS.) REKHA SINGH GANGULI

VS RESPONDENT: UNITED INDIA INSURANCE CO. LTD.

COMPLAINT REF: NO: KOL-G-051-2022-0007 AWARD NO:IO/KOL/A/GI/0026/2021-2022

1.

Name &Address OfThe Complainant

Dr. (Mrs.) Rekha Singh Ganguli C-57, Jal Vayu Vihar, Sector-III, Block LB Salt Lake, Kolkata – 700 098.

2.

Type Of Policy: Life / Health / General Policy Details:

Policy Number Sum Assured From Date To Date DOC Premium Policy Term Paying Term 1203004219P14083561

04-01-2020 03-01-2021

3. Name of insured Dr. (Mrs.) Rekha Singh Ganguli

4. Name of the insurer UNITED INDIA INSURANCE CO. LTD

5. Date of receipt of the Complaint 13-Aug-2021

6. Nature of Complaint Non-settlement of claim

7. Amount of Claim 30,00,000.00

8. Date of Partial Settlement N/A

9. Amount of relief sought 30,00,000.00

10. Complaint registered under Insurance Ombudsman Rules 2017

Rule 13(1)(a) – Delay in settlement of claim.

11. Date of hearing Place of hearing

22-Jun-2021 Kolkata


a)For the Complainant Dr. Rekha Singh Ganguly

b)For the Insurer Shri Vijay Sangtani

13. Complaint how disposed By conducting online hearing

14. Date of Award 30-Aug-2021

Brief Facts of the Case:The complainant has stated in her complaint that the insured, Colonel, Prosenjit Ganguli was holding a Savings Bank Account with State Bank of India as Joint Account with wife, Dr. Rekha Singh Ganguli and the said account was insured under Group Personal Accident Insurance (Death)/Air Accident (Death) Cover for Salary Package with United India Insurance Company. On 5th November, 2020, the insured, Colonel Prosenjit Ganguli had accidentally fallen from his balcony in Turf View, Kolkata Military Station Complex and succumbed to his injuries on 6th November, 2020 at Command Hospital, Alipore, Kolkata.The complainant lodged the claim for Rs.30 lakh and submitted all the documents (Death Certificate, Post-Mortem Report, Police Final Report, Casualty Certificate, Inquest Report etc.) as required by the Insurance Company within the stipulated time but the Insurance Company did not settle the claim till date. Hence, being aggrieved, the complainant has lodged complaint for redressal of her grievance. The Insurance Company has stated in their self-contained note that as per policy terms and conditions of the SBI GPA Policy, i) FIR, ii) Post-mortem Report, iii) Death Certificate are mandatory for settlement of the claim.

In the captioned claim, no FIR has been filed and only Inquest Report with Particular of Occurrence from the Police has submitted by the climant . Under Particular of Occurrence from the police has clearly mentioned as “N.B : This is not a copy of Police Report but merely an abstract of such particulars as may be useful to persons concerned.”

Further, the claimant has mentioned in the Claim Form under Details of Accident as “unattended death (Polytramuma) and Post Mortem Report also mentioned that the person died due to fall from 4th floor on 05-11-2020 at 23.50 hrs declared brought dead on 06-11-2020 at 00.10 hrs. which creates doubt and possibility of suicide cannot be ruled out in this case.

The Insurance Company has requested to the claimant to arrange the FIR as it is a mandatory document. However, the same has not been provided by the claimant till date.

Due to the complexities involved in the claim, an Investigator has been appointed for investigation and are awaiting for the report (The Insurance Company has submitted the Investigation Report alongwith self-contained note).

The claim is still open and under investigation and hence, not repudiated. However, the claimant has not providing the required documents as mentioned above.

Contention of the complainant:

The complainant has stated in the hearing that his husband, Shri Prosenjit Ganguli was covered under SBI Group Personal Accident Policy who died due to fall from his balcony. The complainant submitted the claim form alongwith all required documents for settlement of the claim. The Hospital Authority had taken action to inform the Police Authority. No formal FIR was lodged.

Contention of the Respondent:

The representative of the Insurance Company has stated in the hearing that the claim is under process. The complainant did not submit the copy of FIR. The claim documents were forwarded to the Higher Authority for their opinion. On receipt of the opinion from the Higher Authority, the Insurance Company will inform to the complainant as well as to this office about the status of the claim.

Observation and conclusions:

It is observed that the complainant as well the representative of the Insurance Company both have attended the hearing online. The complainant has stated in the hearing what she already stated in her written complaint submitted to this office. The representative of the Insurance Company has stated that the claim is under process.

It is found from the submitted documents as well as submissions made by both the parties during the course of hearing that as per Investigation Report and Legal Opinion submitted by the Insurance Company, there raises doubts on the cause of death of the deceased :

a) only two persons, late Colonel Ganguli and his wife Mrs. Ganguli at the time of alleged accident;

b) no history of mental or physical disease ever reported;

c) nowhere in the Medico Legal Report or Death Certificate or Post-mortem Report, there is any mention of consumption of alcohol or any toxic substance by Colonel;

d) the fence/railing of balcony is 4 feet in height and it is difficult to fall to the ground by accident;

e) no blood/splinter marks are visible in photographs;

f) the doctor conducting post-mortem examination did not mention whether the nature of injuries/forms on the body of Col. Ganguli were homicidal, suicidal or otherwise;

The Insurance Company has repudiated the claim as per Clause No.4 in Exclusions under the policy specifically excludes the liability under policy in case of death from intentional self-injury, suicide or attempted suicide. Thus, the cause of death is not clear, in the contrary, there are clear suspicion as to cause of death. The claimant could not provide any documentary evidence which proves that the death is accidental.

AWARD

Taking into account the facts and circumstances of the case and submissions made by both the parties during the course of hearing and after going through the documents on record, it is observed from the submitted documents that the cause of death is not clear. As such, the decision of repudiation made by the Insurance Company is in order.

Hence, the complaint is dismissed without any relief to the complainant.

“If the decision is not acceptable to the complainant, she/he is at liberty to approach any other Forum/Court as per Law of the Land against the Respondent Insurer.”

Dated at Kolkata on Day of 30th August, 2021 SHRI P K RATH

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, Kolkata (States of West Bengal, Sikkim and Union Territories of Andaman & Nicobar Islands)

(UNDERRULENO.16/17OFTHEINSURANCEOMBUDSMANRULES,2017) Ombudsman Name: P.K. RATH

CASE OF COMPLAINANT– MADHURITA MAZUMDER VS

RESPONDENT: THE NEW INDIA ASSURANCE CO. LTD. COMPLAINT REF: NO: KOL-G-049-2122-0011

AWARD NO:IO/KOL/A/GI/0025/2021-2022

1. Name &Address OfThe Complainant

Ms. Madhurita Mazumder 177, M. B. Road, Shibachal More Birati, Kolkata-700 051.

2.

Type Of Policy: Life / Health / General Policy Details:

Policy Number Sum Assured From Date To Date DOC Premium Policy Term Paying Term 51240342180

100000051 No Policy

copy - - - - - -

3. Name of insured Ms. Madhurita Mazumder

4. Name of the insurer The New India Assurance Co. Ltd.

5. Date of receipt of the Complaint 27-Apr-2021

6. Nature of Complaint

7. Amount of Claim 2,00,000.00

8. Date of Partial Settlement

9. Amount of relief sought 2,00,000.00


13(1)(b) – any partial or total repudiation of claims by

an Insurer

11. Date of hearing Place of hearing 16-Jul-2021

Kolkata


a)For the Complainant Mrs. Shibani Mazumder

b)For the Insurer Shri Bishnu Pada Sana


14. Date of Award 16-Aug-2021

Brief Facts of the Case:

The complainant has stated in the complaint that her father (insured), Shri Biswajit Mazumder was covered under a Group Personal Janata Accident Policy with the New India Assurance Company through National Institute of Fashion Technology at Salt Lake, Kolkata. On August, 2018, the insured met with railway accident

and died. After death, the complainant lodged claim to the Insurance Company but the Insurance Company repudiated the claim. As per Repudiation Letter, the Insurance Company has repudiated the claim showing the reason that “as per reports of investigation and other relevant documents, it reveals that the incident occurred while the victim was passing by the closed railway level crossing which is highly restricted. It is an act of breach of law which is an exclusion of the policy. Hence, the claim is not maintainable under purview of the policy conditions.” Being aggrieved, the complainant lodged complaint to this office to redress her grievance.

The Insurance Company has stated in their self-contained note that “the victim Biswajit Majumder, a resident of Birati, Kolkata, covered under the aforesaid insurance policy died due to a railway accident occurred on 26.09.2018 at about 19.20 hours while crossing a manned controlled railway crossing Railway Gate No. 5 ( Railway Gate Man was Mr. Aman Hela) carelessly in between Birati & Durganagar railway Station by a 33626 DN Sealdah bound train, at the time when the gate was closed for smooth passing of the said local train.

ln this context, our contention is that an adult, a resident of that area, having full knowledge of the outcome crossed the railway track while the railway gate was closed due to smooth movement of train, which was break of law as per Sec.154 of Railways Act, 1989 which states inter alia 154. Endangering safety of persons travelling by railway by rash or negligent act or omission.- if any person in a rash and negligent manner does any act, or omits to do what he is legally bound to do, and the act or omission is likely to endanger the safety of any person travelling or being upon any railway, he shall be punishable with imprisonment for a term which may extend to one year, or with fine, or with both.


Mrs. Shibani Mazumder, mother of the complainant, has stated in the hearing that her husband was covered under Group Personal Accident Policy with the New India Assurance Co. Ltd. On 26-09-2018, her husband died in Railway accident. Thereafter, the complainant lodged claim form alongwith relevant documents for settlement. But the Insurance Company repudiated the claim.


The representative of the Insurance Company has stated in the hearing that Shri Biswajit Mazumder died due to a railway accident on 26-09-2018 while crossing manned controlled railway crossing Railway Gate carelessly by train at the time when the gate was closed for smooth passing of the said local train.

As per Investigation Report and other relevant documents, it reveals that the incident occurred while the victim was passing by the closed railway level crossing which is highly restricted. It is an act of breath of law which is an exclusion of the policy. Hence, the claim has been repudiated.


It is observed that Mrs. Shibani Mazumder, mother of the complainant, has attended the hearing physically at this office premises whereas the representative of the Insurance Company has attended the hearing online. Mrs. Shibani Mazumder has stated what already stated in the written complaint submitted to this office. The representative of the Insurance Company has stated in the hearing that the claim has been repudiated as per policy terms and conditions.

It is observed that the Insurance Company has forwarded the documents alongwith Investigation Report to this office and on further request in respect of police report, the Insurance Company has submitted the G.R.P. Report. It is found from the Report that the diseased was crossing the railway line carelessly, at that time the train dashed him and received injuries on his person and succumbed on the spot. It was a Railway accident in nature and there is no foul play detected behind the death. On the basis of the same submitted documents, HDFC Ergo General Insurance Company and Reliance General Insurance Company settled the claims amounting to Rs.10,00,000/- and Rs.20,00,000/- respectively.

It is also noted that the complainant submitted all the required claim documents 28-03-2019 but the Investigator deputed by the Insurance Company submitted the Investigation Report on 19-09-2019 and the decision of repudiation of claim was intimated to the complainant on 29-11-2019 after a lapse of inordinate delay.

It is observed that the Insurance Company repudiated the claim showing the reason - the incident occurred while the victim was passing by the closed railway level crossing which is highly restricted. It is an act of breach of law which is an exclusion of the policy.

AWARD

Taking into account the facts and circumstances of the case and submissions made by both the parties during the course of hearing and after going through the documents on record, it is found from the submitted documents as well as submissions made by both the parties during the course of hearing, the decision of repudiation of the claim made by the Insurance Company is not correct and justified Besides, HDFC Ergo General Insurance Company and Reliance General Insurance Company settled the same claims on the basis of same documents. Hence, the decision of repudiation made by the Insurance Company is set aside and the Insurance Company is directed to admit the claim alongwith interest from the date of submission of claim documents @ 2% above the Bank rate prevalent at the beginning of the financial year.

The attention of the Complainant and the Insurer is hereby invited to the following provisions of Insurance

Ombudsman Rule 2017.

As per Rule 17(6) of the said rules the Insurer shall comply with the Award within 30 days of the receipt of the

acceptance letter of the Complainant and shall intimate the compliance to the Ombudsman.

Dated at Kolkata on Day of 16th August, 2021 SHRI P K RATH

INSURANCE OMBUDSMAN


(UNDERRULENO.16/17OFTHEINSURANCEOMBUDSMANRULES,2017) Ombudsman Name: P.K. RATH CASE OF COMPLAINANT – Mr. Ashoke Kr Saha

VS RESPONDENT: -- United India Insurance Co. Ltd

COMPLAINANT REF: NO: KOL-H-051-2122-0164 AWARD NO:

IO/KOL/A/HI/0194/2021-2022

1.

Name &Address OfThe Complainant

Sri Ashoke Kumar Saha 12A/9, Chanditala Lane, Tollygunge Kolkata- 700040, West Bengal.

2.

Type Of Policy: Health Policy Details: Policy Number Sum Assured From Date To Date DOC Premiu

m Policy Term Paying Term

HHSBO70001

4743

4 LAKH

01/10/2019

30.09.2020

13.12.2019

Not mentio

ned.

Gr.

mediclaim

Annual

3. Name of insured Gangamoyee Saha

4. Name of the insurer United India Insurance Co. Ltd


6. Nature of Complaint Non settlement of claim

7. Amount of Claim 63172/-


9. Amount of relief sought 63172/-


Rule 13(1) (b).


12.08.2021 Kolkata

12. Representation at the hearing --

a)For the Complainant Sri Ashok Kr. Saha

b)For the Insurer Ms Pamela Pinto

13. Complaint how disposed Through on line hearing.

14. Date of Award 16.08.2021

Brief Facts of the Case: --

Sri Ashoke Kr.Saha, ex senior manager of the then India Bank, later on shifted to Allahabad

Bank, was covered under group Mediclaim Policy with the present Insurer. His mother, aged

77 years expired on 14.11.2020 after suffering from LRTI/Sepsis & treated at Dr NC Dutta

Memorial Hospital, Rampurhat, Birbhum, during the period 13.12.2019 to 17.12.2019. Total

reimbursement claim submitted for Rs 63172/- .

Initially at the time of complaining, no claim entertained by the Insurer. In the mean while it

is observed that Rs 35847/- allowed & paid on 28.07.2021 out of total claim of Rs 61672/-.

Deduction of Rs 25825/- was due to—1) 500/--- (Spondon Diagnosis centre) Path Report not

enclosed. 2)1600/- patient name not mentioned in bill, for purchase of nebulizer. 3) 17325 +

800/- + 5620/- = Rs 23745/-, Payment receipt not submitted. Present claim is for Rs 25825/-.

Contention of the complainant:-

Complainant during the course of hearing stated that against payment of Hospital Bill for a

sum of Rs 56985/-, he had already submitted receipt to the Insurance Company in full through

four receipt in denomination of 26985/-, 5000/-, 5000/- & 20000 respectively. For three bills

he is having acknowledgement & for Rest bill of Rs 26985/- as asked for the concern TPA, is

reflected in respective bill , Stamped & countersigned by the hospital. So denial amount of

Rs 23745/- (17325/- + 800/- + 5620/-) which were not considered by Insurer, is not justified.

It should be considered. He confirmed that he will be submitting the required documents in

support of his statement to the Honorable Ombudsman by next day.


While settling the claim, Rs 25825/- not considered either for incomplete documents or in absence of Money receipt. Bill in place of money receipt does not justify proof of payment. Hence not payable.


1) No authentic documents for payment as against Complete Hospital bill could have been provided by Complainant though confirmed by him during the time of hearing.

2) No adjustment money receipt as against final bill of the Hospital could have been provided by the Complainant.

AWARD

Taking into account the facts & circumstances of the case & the submissions made by both

the parties in hearing, also on going through the submitted documents it is observed that

the balance Insurance Claim as raised by Complainant , could not be substantiated by him

through proper & appropriate money receipt, reflecting details of payment particulars to

the Hospital & /or other authorities. Therefore, the decision of the Insurer towards

settlement of the claim as full & final settlement seems to be justified & no further payment

is allowed by the forum to the Complainant as against the said Complaint. The claim case is

therefore closed & treated as disposed of.

The attention of the Complainant and the Insurer is hereby invited to the following

provisions of Insurance Ombudsman Rule 2017.

P K RATH

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATES OF WEST BENGAL, SIKKIM AND UT OF ANDAMAN & NICOBER ISLANDS

(Under Rule No.16(1)/17 of The Insurance Ombudsman Rules -2017) OMBUDSMAN–SHRI P. K. RATH

Case of Complainant : Mr. Atindra Chandra Sengupta VS

Respondent : The New India Assurance Co. Ltd. (Kolkata) COMPLAINT REF NO: KOL-H-049-2122-0178 AWARD NO:IO/KOL/A /HI/ 0169 / 2021-2022

1. Name & Address of the Complainant Mr. Atindra Chandra Sengupta 103, RPM Road, Uma Nivas, Block - C, Flat No. 311, Uttaroara, Hooghly - 712258

2. Type of Policy: Group Mediclaim Policy Number Sum

Assured From Date To Date DOC Premium Policy

Term Paying Term

511700/34/20/04/00000002 2,50,000 01/04/2020 31/03/2021

3. Name of the insured Mr. Atindra Chandra Sengupta 4. Name of the insurer The New India Assurance Co. Ltd. (Kolkata)

5. Date of Receipt of the Complaint 14-Jul-2021 6. Nature of Complaint Refusal of Payment for Critical Disease Claim

7. Amount of Claim 8. Date of Partial Settlement 9. Amount of relief sought Rs.5,00,000/-

10. Complaint registered under IOR-2017 13 (1) (b)


17-Aug-2021 Kolkata

12. Representation at the hearing a) For the Complainant Mr. Atindra Chandra Sengupta b) For the insurer Mr. Kalyan Ganguly

13. Complaint how disposed By Conducting online Hearing 14. Date of Award/Order 24-Aug-2021


Policy Name :: Grp. Med. Pol. for Garden Reach Shipbuilders & Engineers Ltd., Policy Type :: Group Mediclaim, Sum Insured :: Rs.2,50,000/- + Max 2 times of the SI for Critical Illness,

Hospitalisation date/s:: 20/03/2021 to 20/04/2021 (Covid-19). The complainant lodged complaints against the Insurance Company in connection with refusal of payment for Critical Disease claim. Hence, this complaint lodged with this office for settlement of claim.


The complainant stated that:

(i) Following a severe acute life threatening Lungs Fibrosis disease arising out of Post

Covid-19 virus illness, he had been admitted at the Apollo Gleneagles Hospital, Kolkata.

(ii) As per RFQ of GRSE GMC Policy for all retired employees (RFQ attached), he is entitled

per family Basic Floater Sum Insured Rs.2.5 lacs & Per Family available limit of the Corporate buffer sum insured Rs.5 lakhs only for Critical Illness specified diseases as clearly mentioned in the said RFQ of technical Clause Bid at page No.8, Clause No.1.5.

(iii) The TPA, Mediassist had sanctioned as final cashless settlement only for Rs.2.5 lakhs

only out of total billed Rs.9.85 lakhs.

(iv) The TPA had declined to pay the balance amount under Critical Illness Clause No.(l) citing the reason that Corona Virus would not come under preview of critical illness conditions. Although in the GRSE GMC RFQ, it was clearly specifically mentioned in the critical clause number 1(5) sub section (L), that Life threatening diseases & septicaemia would be covered under critical illness (although a typographical mistakes were done in the said RFQ to put one “&” between Life threatening and Sepeticemia. Although it was brought immediately the notice of the said DO by GRSE Management in due course for rectifications by letter.

(v) Covid-19 was not effected in the year 2019 when GRSE GMC RFQ was drafted and the

same was submitted to the said underwriting office on 15/01/2019. Since corona Virus was not effected in the year 2019, it was quite obvious that the said virus should not be kept in the RFQ to be considered as critical illness. As such GRSE Management mentioned in the RFQ specifically and clearly to be considered all life threatening diseases as critical illness under clause No.1 (5) subsection (L).

Being aggrieved and dissatisfied with the Non-settlement of Critical Disease claim by the Insurance Company, the complainant has approached this office for redressal of his grievance. The complainant has also given his unconditional and irrevocable consent to the Insurance Ombudsman to act as a mediator between himself and the insurance company and to give recommendation as per consent form.


The Insurance Company vide their SCN (Self Contained Note) has stated that:

(i) 71 years mail old patient admitted in Apollo Gleneagles Hospital, Kolkatal for treatment Covid-19. Total Claimed amount is Rs.9,85,798/- and settled for Rs.2,50,000/- as per entitled (Maximum) Sum Insured.

(ii) As per agreed Policy Terms & Condition of the policy, buffer can be used only under

16 specific named Critical Illness. Hence, considering the stated fact, the amount available under corporate buffer as COVID-19 is not listed under agreed Critical Illness for utilisation of corporate buffer.

(iii) As per Cl.No.1.5 – in case of special disease / critical illness disease listed, Buffer Sum

Insured will be used subject to maximum 2 times of eligible sum insured.

(iv) Hence, they cannot be paid more than the eligible sum insured and cannot consider the illness (COVID-19) as special / critical disease or illness as it was not considered by the insured (GRSE) at the time of published their technical bid /terms and condition on what basis premium quotation submitted and accordingly as L-1 bidder, they charged the premium as per their quotation.

The Insurance Company has also given their consent to the Insurance Ombudsman to

act as a mediator between the Complainant and themselves and to give his

recommendation for the resolution of the complaint.


Both the parties were present and participated in the hearing and following documents were placed for perusal:

(a) Complaint letter along with annexures, (b) Policy Copy, (c) Annexure–VI-A & (d) Self Contained Note from the insurer.

AWARD Taking into account the facts & circumstances of the case and the submissions made by both the parties during the course of hearing & after going through the documents on record it is observed that the settlement is in consonance with the policy issued to the Complainant. Hence, the complaint is dismissed without any relief to the complaint. Dated at Kolkata on the 24TH Day of August, 2021. SRI P. K. RATH

INSURANCE OMBUDSMAN STATES OF WEST BENGAL, SIKIM, A & N ISLAND

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, Kolkata

(States of West Bengal, Sikkim and Union Territories of Andaman & Nicobar Islands)

(UNDER RULE NO.16/17 OF THE INSURANCE OMBUDSMAN RULES, 2017) Ombudsman Name: Shri P.K.RATH CASE OF COMPLAINANT – BIPLAB BASU

VS RESPONDENT: NATIONAL INSURANCE CO LTD. MUMBAI

COMPLAINT REF: NO: KOL-H-048-2122-0084 AWARD NO:IO/KOL/A/HI/0193/2021-2022

1.

Name & Address Of The Complainant

Biplab Basu 414 Kalikapur Road, Ahili Apartment Gitanjali Park Kolkata - 700099. [98316 36817]

2.

Type Of Policy: Life / Health / General Policy Details: Group Mediclaim Policy with IBA

Policy Number

Sum Assured

From Date

To Date DOC Premium

Policy Term

Paying Term

251100502010000352

4 lacs 1.11.2020.

31.10.2021

3. Name of insured Biplab Basu

4. Name of the insurer National Insurance Co. Ltd. Mumbai

5. Date of receipt of the Complaint 05-May-2021

6. Nature of Complaint Repudiation of claim

7. Amount of Claim 71297.00


9. Amount of relief sought 71297


13(1)(b)


24-July-2021 / 17th August 2021 Kolkata


a) For the Complainant Biplab Basu

b) For the Insurer Atul Malhotra


14. Date of Award 27th Aug-2021


Smt. Bani Basu, wife of the Complainant was admitted as per Doctor’s advice at AMRI, Kolkata with the ailment of Ventral Chest Pain on 26.12.2020 termed by Hospital as PIVD

Acute Costochondritis, DM, HTN and was discharged on 30.12.2020 and spent Rs.71297/- including post hospitalization. During hospitalization she was treated IV pantoprazole and other supportive care, Ultra Sonic ray on left arm applied besides other routine investigations. The Claim has been categorized as non-admissible on the ground that the patient was admitted for investigation and evaluation purpose and no active line of treatment given during hospitalization under Clause No. 4.1(a) of IBA GMC Policy with Indian Bank.


The wife of the complainant was hospitalized with severe chest and back pain since 26.12.2020 and as per her treating doctor’s advice she was hospitalized. Her cashless treatment was denied. The claim was not sanctioned on the plea that the patient was admitted only for investigation and evaluation purpose and no action time of treatment was provided during hospitalization.

Contention of the Respondent.

It is stated that the Cashless hospitalization was requested by the Insured but it was found that the patient was admitted for investigation purpose hence cashless facility was not provided. On submission of treatment documents, it was found the patient was admitted only for investigation and evaluation purpose and no active line of treatment given during hospitalization and the claim was repudiated under Clause No. 4.1(a) of IBA GMC Policy with Indian Bank.


It is observed that the claim was not settled as the patients Smt. Bani Basu was admitted for ventral chest pain and treated conservatively with IV pantoprazole and other supportive care, Ultra Sonic ray on left arm applied besides other routine investigations. Following documents are available in the file a) Complaint letter with Annexure VI-A, b) Discharge Summary from the Nursing Home, c) Self Contained Note.

AWARD

Taking into account the facts & circumstances of the case, the submissions made by both

the parties during the hearing and after going through the documents on record it envisages

that the patient was hospitalized as per physician’s advice with the ailment of Ventral Chest

Pain and diagnosed as PIVD Acute Costochondritis DM, HTN the patient was treated

conservatively with IV fluids, and other supportive measures. Ultra sonic Ray was applied

on left arm besides other routine investigations.

It is for the treating doctor to decide the course of treatment to be carried out and it is for the doctor who decides what is beneficial for the patient. As such, the decision of the Insurer towards rejection of the claim seems to be not justified. In view of the foregoing the Insurer’s repudiation is set aside and the Insurance Company is directed to admit the claim and reimburse the amount to the Complainant being full and final settlement of the claim subject to deductions, limitation, sub-limits and non-payables along with interest from the date of submission till the date of settlement at the rate provided in Ombudsman Rule of 2017. Hence, the complaint is thus treated as disposed of.


provisions of Insurance Ombudsman Rule 2017:

As per Rule 17(6) of the said rules the Insurer shall comply with the Award within 30 days of

the receipt of the award and intimate compliance of the same to the Ombudsman.

Dated at Kolkata on 27th Day of August, 2021 SHRI P K RATH

INSURANCE OMBUDSMAN


(UNDER RULE NO.16/17 OF THE INSURANCE OMBUDSMAN RULES, 2017) Ombudsman Name: P.K.RATH CASE OF COMPLAINANT – DEBATOSH GHATAK

RESPONDENT: NATIONAL INSURANCE CO LTD. MUMBAI COMPLAINT REF: NO: KOL-H-048-2122-0174 AWARD NO:IO/KOL/A/HI/0199/2021-2022

1.


Debatosh Ghatak 3 Humayun Kabir Sarani Block A New Alipore Kolkata 700053

2.

Type Of Policy: Life / Health / General Policy Details: IBA Group Mediclaim Policy - PNB Retirees


10000329 400000 1-11-2020 31.10.2021

3. Name of insured Debatosh Ghatak

4. Name of the insurer National Insurance Co. Ltd., Mumbai

5. Date of receipt of the Complaint 12-July-2021

6. Nature of Complaint





13(1)(b)


17 August-2021 Kolkata


a) For the Complainant Debatosh Ghatak



14. Date of Award 31st-August-2021


The Complainant Shri Debatosh Ghatak retired Bank Officer underwent Surgery for Inguinal Hernia along with Orchidectomy at Paramount Nursing Home, Kolkata during 27-3-2021 to 9-4-2021. Said hospital is not covered under PPN package. A sum of Rs. 172339/- was spent for the surgery. The claim has been settled at Rs. 97857/- applying the highest PPN rate in the same geographical area as it is obligatory to follow the PPN rates in PPN zone. On review of the claim a sum of Rs.35000/- was also paid to the claimant. Thus, the complaint is stands now for non-payment of balance hospitlisation expenses of Rs.39482/-


The Claim has been settled arbitrarily and adopting unreasonable method. The claim was settled under PPN rates although the hospital where I admitted is not under PPN arrangement with the Insurer. He is also in receipt of a sum of Rs. 35000/- on August16, 2021


The complainant underwent surgery for Hernia at a Nursing Home who are not under PPN package. Had he been admitted in the PPN networked hospital he can avail the cashless facility also. The claim has been settled at Rs. 97857/- applying the highest PPN rate in the same geographical area as it is obligatory to follow the PPN rates in PPN zone. This is as per policy terms and condition under heading “Reasonable & Customary Charges” which are the standard charges for service or supplies. On further review of the claim a sum of Rs.35000/- has already been settled by Ins.co.


It is observed that the following documents are available in the file a) Complaint letter with Annexure VI-A, b) Discharge Summary from the Nursing Home, c) Self Contained Note. Subsequently the Complainant has sent the Doctors Bill, bill for Sister in charge and a detailed bill from hospital,

AWARD

Taking into account the fact & circumstances of the case and the submissions made by both

the parties during the course of hearing and after going through the documents on record,

and taken into consideration of further release of Rs.35000/- it is observed that the decision

taken by the Insurer towards settlement of the claim is just and proper as per prevailing policy

condition.

The subject complaint is therefore dismissed without any further relief to the Complainant. With this the complaint is closed and treated as disposed of.



As per Rule 17(6) of the said rules the Insurer shall comply with the Award within 30 days

of the receipt of the award and intimate compliance of the same to the Ombudsman.

If the decision is not acceptable to complainant, he is at liberty to approach any other

Forum/Court of the Land against the respondent insurer.

Dated at Kolkata on 31st Day of August, 2021 SHRI P K RATH

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, Kolkata

(States of West Bengal, Sikkim and Union Territories of Andaman & Nicobar Islands)

(UNDER RULE NO.16/17 OF THE INSURANCE OMBUDSMAN RULES, 2017) Ombudsman Name: P.K.RATH CASE OF COMPLAINANT – TARUN KUMAR CHATTEREEE

VS RESPONDENT: NATIONAL INSURANCE CO LTD MUMBAI

COMPLAINT REF: NO: KOL-H-048-2122-0011

1.


Tarun Kumar Chatterjee 140/3/1 Sarat Chatterjee Road Shibpur, Howrah 7111012 [9903935761]

2.

Type Of Policy: Life / Health / General Policy Details: Group Mediclaim Policy with IBA - Bank of India


10000352 400000 1.11.2020 31.10.202

1

3. Name of insured Tarun Kumar Chatterjee

4. Name of the insurer National Insurance Co. Ltd. Mumbai


6. Nature of Complaint Repudiation of Claim





13(1)(b)


24-May-2021 /14th July 2021 / 17th August Kolkata


Smt. Shyamali Chatterjee, wife of the Complainant Shri Tarun Kumar Chatterjee, (Ex-Employee of Bank of India) suffered Carcinoma of her Right Breast for which she was admitted at Ashok Nursing home and Health Care Ltd., Kolkata for three times in the current policy period 20.11.2020,11.12.2020 and 4.01.2021for administering the Chemotherapy on day care basis. The claims have been repudiated by the Insurance Co. on the plea that the patient got admitted as a diagnosed case of Carcinoma Breast and underwent adjuvant chemotherapy which is not appeared in their day care list of treatment and hence the claim had been repudiated under Section 3.3 of policy terms and condition.


It is stated by the complainant Shri Tarun Kumar Chatterjee that the claims were lying unsettled for long by the National insurance Co. Ltd. Whereas the claim for hospitalization on 7.10.2020 was reimbursed for the same ailment by the previous insurer United India Insurance Co.ltd. against Policy No. 500100/28/19/P112943567 and claim No. MD15889016 for Rs.17681/-


The Claim were repudiated by the Insurance Co. under Policy Additional Coverage Clause No. 3.3 since Adjuvant Chemotherapy is not listed in day care list


It is observed that the ailment is continuing since long and the claim lodged with the previous Insurer of IBA – United India Insurance Co. Ltd. where the earlier claim for the same ailment was settled. With the change of Insurer by the Employer, she is debarred from getting the same claim as the present Insurer does not have the same cover listed in their day care list.

AWARD

Taking into account the fact & circumstances of the case and the submissions made by both the parties during the course of hearing and after going through the documents on record the repudiation of the claim is not justified in the light of an Exclusion as per policy terms and condition vide No. 3.3 where it states that Adjuvant Chemotherapy is not listed in their day care list. The current Mediclaim policy of the Complainant is a continuing group policy chosen by the Employers which was previously with another insurer wherein she had received the benefit for the same ailment. As such at present for the post chemotherapy for same ailment she can not be deprived of getting a similar cover.


a) For the Complainant Tarun Kumar Chatterjee



14. Date of Award 27th Aug-2021

In view of the foregoing the Insurer’s repudiation is set aside and the Insurance Company is directed to admit the claim and reimburse the amount to the Complainant being full and final settlement of the claim subject to deductions, limitation, sub-limits and non-payables along with interest from the date of submission till the date of settlement at the rate provided in Ombudsman Rule of 2017. Hence, the complaint is treated as disposed of.

The attention of the Complainant and the Insurer is hereby invited to the following provisions

of Insurance Ombudsman Rule 2017.




INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, Kolkata (States of West Bengal, Sikkim and Union Territories of Andaman & Nicobar

Islands) (UNDER RULE NO.16/17 OF THE INSURANCE OMBUDSMAN RULES, 2017)

Ombudsman Name: P.K.RATH CASE OF COMPLAINANT – PROSUN DAS VS

RESPONDENT: United India Insurance Co. Ltd. Mumbai COMPLAINT REF: NO: KOL-H-051-2122-0179 AWARD NO: IO/KOL/A/HI/0192/2021-2022

1.

Name & Address of The Complainant

PROSUN DAS 7 New South Park PO: Regent Estate PS: Jadavpur, BaghaJatin Kolkata 700092

2.

Type Of Policy: Life / Health / General Policy Details: Allahabad Bank IBA Mediclaim and TOP UP Policy

Policy Number

Sum Assured

From Date

To Date DOC

Premium

Policy Term

Paying

Term

5001002819P11278

6782

400000 1.11.2019

31.10.2020

5001002819P11278

6782

3. Name of insured Prosad Kr Das (72)

4. Name of the insurer United India Insurance Co. Ltd. Mumbai

5. Date of receipt of the Complaint 14-Jul-2021

6. Nature of Complaint Non-settlement of a claim





13(1)(b)


17 August-2021 Kolkata


a) For the Complainant Prosun Das

b) For the Insurer Pamela Pinto


14. Date of Award 30-August-2021


The father of the complainant was hospitalized for Acute Severe Pancreatitis on 17-5-2020 till 31-5-2020 at Narayan Hridayalaya Kolkata and from 31st May to 5th June 2020 at Cure Centre Nursing Home Kolkata where he breathed his last. Total bill was Rs.610468 at Narayana Hridayalaya and Cashless Rs,450000 was approved. Subsequently Rs.47612 was paid and a sum of Rs. 87856 remains unpaid after discount. At Cure Centre Nursing Home, the Hospitalisation bill was Rs, 208728/- which was totally unpaid with the reason 4.5 that the patient was an Alcoholic and alcohol related ailment is not payable as per policy terms and condition. It is also noted that the hospital name was mentioned as Jamdar Hospital Pvt Ltd. which is not true. BUT in the patient History Sheet of Cure Centre Nursing Home, it is mentioned that he was “Mild to moderate Alcoholic (for 6 months back)”

Contention of the complainant: The complainant intimated that his father was first admitted at NH R N Tagore Hospital and subsequently shifted to Cure Centre Nursing Home Kolkata where he breathed his last. Son of the Insured has intimated that his father was never admitted at Jamdar Hospital Pvt Ltd. neither he was an alcoholic. He wants settlement of unpaid hospitalization expenses of Rs.295000/-

Contention of the Respondent: As per SCN the first claim was approved cashless for Rs.450000 and post hospitalisation treatment was also reimbursed. In the Patient History Sheet of Cure Centre Nursing Home there is mention that the patient was ‘Mild to Moderate Alcoholic (for 6 months Back)’. Subsequent hospitalization was not approved as per policy T&C clause No. 4.5 of IBA GMC policy the claim has been repudiated.

Observation and conclusions: Both the parties were participated in the hearing. It is observed that his first claim was approved cashless and post hospitalization expenses was also settled. Following are available in the file a) Complaint letter with Annexure VI-A, b) Discharge Summary for both the Nursing Home, c) Repudiation letter and d) Self Contained Note.

AWARD

Taking into account the fact & circumstances of the case and the submissions made by both

the parties during the course of hearing and after going through the documents on record it

is observed that the claim is already settled for first hospitalization and for another part of

this claim is rejected citing a note ‘Mild to Moderate Alcoholic (for 6 months Back)’ which is

an inconclusive remark which is not a valid reason for repudiation The Company cannot

substantiate the cause of ailment was due to that. Hence the repudiation of the second claim

is not justified.

In view of the above, the Insurer’s repudiation is set aside and the Insurance Company is

directed to the admit the claim and pay the claim amount to the complainant being full and

final settlement of the claim subject to deductions, limitations, sub-limits and non-payables,

as per policy terms & conditions along with interest from the date of submission till the date

of settlement at the rate provided in Ombudsman Rule of 2017. Hence, the complaint is

treated as disposed of.






INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE - THE INSURANCE OMBUDSMAN, LUCKNOW

(UNDER RULE NO: 16(1)/17 OF THE INSURANCE OMBUDSMAN RULE 2017)

Mr. Kashi Ram…………..……....………………. Complainant

V/S

HDFC Ergo General Insurance Company Limited…………..………..…………Respondent

COMPLAINT NO. LCK-H-018-2122-0025 ORDER NO. IO/LCK/A/HI/0009/2021-22

1. Name & Address of the Complainant Mr. Kashi Ram,

D-1/81, Sector-F, Janki Puram,

Lucknow-226021.

2. Policy No:

Type of Policy

Duration of policy/DOC/Revival

160100/12587/2019/A018168

Group Assurance Health Plan

10.09.2019 to 09.09.2020

3. Name of the life insured


Self

Mr. Kashi Ram

4. Name of the insurer HDFC Ergo General Insurance Company Limited

5. Date of Repudiation/Rejection 18.09.2020

6. Reason for repudiation/Rejection Insured’s name cannot be changed


8. Nature of complaint Wrong mention of insured’s name

9. Amount of Claim Rs.5,00,000.00

10. Date of Partial Settlement ---

11. Amount of relief sought Rs.5,00,000.00

12. Complaint registered under Rule Rule No. 13(1)(b) of Ins. Ombudsman Rule 2017

13. Date of hearing/place On 04.08.2021 at Lucknow


a) For the Complainant Present

b) For the insurer Present [ Mr.Manoj Prajapati through virtual hearing]

15. Complaint how disposed Dismissed

16. Date of Award/Order 04.08.2021

17. Mr. Kashi Ram (Complainant) has filed a complaint against HDFC Ergo General Insurance

Company Limited (Respondent) challenging repudiation of her health claim.

18. Brief Facts Of the Case:- The complainant Mr. Kashi Ram was insured under Group Health Policy for

period 10.09.2019 and 09.09.2020. In his proposal submitted on 09.09.2019 he had proposed the

name of his son Mr. Manoj Kumar to be insured under medical cover. Proposal form was submitted to

his bank, Central Bank of India. Brief facts of the case are as under :

• Policy in question started on 10.09.2019 [period 10.09.2019 to 09.09.2020.]

• In proposal form dated 09.09.2020, Mr. Kashi Ram proposed his son Mr. Manoj Kumar for

health insurance cover of Rs.2 lacs.

• On receipt of policy certificate and health insurance card, he noticed that name of insured was

Mr. Kashi Ram and not Mr. Manoj Kumar.

• He did not raise any objection in writing.

• He submitted a “Change request form” on 09.09.2020 [ the date on which policy period was

ending.]

• “Change request form” did not have any option to change insured’s name.

• Bank debited his renewal premium Rs.5052/- in his account on 04.09.2020.

• The insured submitted a “premium refund request letter” to the bank on 21.09.2020 to refund

his premium deducted from his account.

• Bank refunded his premium amount Rs.5052/- in his account on 14.10.2020.

Now the complainant has no right to ask for refund of premium for policy

No:160100/12587/2019/A018168 period 10.09.2019 to 09.09.2020.

In their SCN/Reply dated 13.07.2021, the respondents have submitted that the policy in question was

a tailormade policy and its terms and conditions were duly agreed by the Master Policyholder i.e.

Central Bank of India. Policy kit containing all relevant documents were duly received by the policy

holder. The insured never approached the company stating that any information given in the

documents in the policy kit was incorrect. The respondent company received the change request form

at the time of renewal and after reviewing the same it was communicated to the complainant that it

was not feasible to change insured’s name. Thereafter insured requested for policy cancellation and

refund of premium and as per his request policy was cancelled and full premium was refunded.

19. The complainant has filed a complaint, correspondence with the respondent. Annexure-VIA duly

filled/signed submitted by the complainant while respondent not filed SCN along with enclosures.

20. I have heard the complainant. I have also heard the respondent’s representative through virtual

hearing and perused the records submitted by both the parties

21. Complainant is a retired bank official who took the policy in question from the respondent under

Group Insurance Plan. In the proposal form, he was the proposer while he made his son as insured. It

appears that when policy was issued name of the insured was shown as Kashi Ram. This fact was well

within the knowledge of the complainant but he did not raise any objection till the policy period

expired. Although as per complainant, he raised oral objection with the bank but there is no record to

show that any written complaint or objection were made by the complainant. Even free-look period

was expired. At the time of renewal of the policy again, policy was renewed and premium was

deducted. A request was made by the complainant for change of name which was also declined on the

ground that as per terms and conditions of the policy, it is not possible. Consequently on 21.09.2020,

complainant made a request for refund of premium for Rs.5052/- which was refunded.

Now the main grievance of the complainant is that an amount of the insurance coverage of

Rs.2,00,000/- alongwith damages of Rs.5,00,000/-be awarded in his favour.

As far as question of award of damages are concerned, no amount was spent by the complainant and

premium amount has already been refunded in his favour. Change of name was not possible as per

terms and conditions of the policy. It was informed by the Chief Grievance Officer & Head of the

respondent that the policy is an individual policy, hence change is not feasible. Accordingly, I am of the

view that the there is no deficiency in the service of the respondent. No relief could be granted in

favour of the complainant. Accordingly, complaint is liable to be dismissed.

Order:

Complaint is dismissed.

22. Let copy of the award be sent to both the parties.

Dated : August 08, 2021 Justice (Retd) Anil Kumar Srivastava

Place : Lucknow Insurance Ombudsman

PROCEEDINGS BEFORE - THE INSURANCE OMBUDSMAN, LUCKNOW

(UNDER RULE NO: 16(1)/17 OF THE INSURANCE OMBUDSMAN RULE 2017)

Mr. Arun Babu Agarwal…………..……....………………. Complainant

V/S

United India Insurance Company Limited…………..………..…………Respondent

COMPLAINT NO:LCK-H-051-2122-0026 Order No. IO/LCK/A/HI/0016/2021-

22

1. Name & Address of the Complainant Mr. Arun Babu Agarwal,

2/127-B, Vijai Kand, Gomtinagar,

Lucknow-226010

2. Policy No:

Type of Policy

Duration of policy/DOC/Revival

5001002819P112943475

Group Health Policy

01.10.2019 to 30.09.2020

3. Name of the life insured


All employees of Bank of India

Indian Bank’s Association A/c Bank of India

4. Name of the insurer United India Insurance Company Limited

5. Date of Repudiation/Rejection Various rejections

6. Reason for repudiation/Rejection Zoledroic acid is not cancer chemo drug


8. Nature of complaint Non payment of genuine claims

9. Amount of Claim Various amounts

10. Date of Partial Settlement --

11. Amount of relief sought --

12. Complaint registered under Rule Rule No. 13(1)(b) of Ins. Ombudsman Rule 2017

13. Date of hearing/place On 12.08.2021 at Lucknow


c) For the Complainant Present [ through virtual hearing ]

d) For the insurer Present [Mrs. Pamela Pinto through virtual hearing ]

15. Complaint how disposed Award

16. Date of Award/Order 12.08.2021

17. Mr. Arun Babu Agarwal (Complainant) has filed a complaint against United India Insurance

Company Limited (Respondent) challenging repudiation of his four claims and also alleging not

settlement of his five claims.

18. Brief Facts of the Case:- The complainant is a retired office of Bank of India. He was covered

under Group Health Policy for period 01.11.2019 to 31.10.2020. He was diagnosed with Prostate

Cancer in 2008. It was operated in 2008 followed by 31 sittings of radiation and oral hormonal

chemotherapy. He was almost normal upto 2017 thereafter cancer spread into bones. He was

referred to RML Hospital, Lucknow whereas he was given chemotherapy both by drip and oral

alongwith zoledronic acid injection for strengthening of bones on various occasions since

05.02.2019 till date on regular intervals. For this procedure, the complainant was hospitalized every

time for a day or more. He has submitted 11 reimbursement claims to the respondent company out

of which only two claims have been settled. Four claims have been repudiated and five claims are

still unpaid.

In their SCN dated 16.06.2021, the respondents have submitted that the patient was suffering from

Prostate Carcinoma with Bone Mets and was being treated by intravenous administration of

injection Zolendronic Acid plus tablet Enzamide without any chemotherapy drug being

administered. This procedure does not fall under the purview of treatments allowed in the list of

day care procedures as per Clause No:3.3 of the policy. In view of the same, the claims were

repudiated.

19. The complainant has filed a complaint letter, annexure VI A, correspondence with respondent

and copy of policy document while respondent filed SCN with enclosures.

20. I have heard the complainant through virtual hearing. I have also heard the respondent

representative through virtual hearing and perused the records submitted by both the parties.

21. Admittedly Complainant was insured with the respondent. He suffered prostate cancer in 2008

which was treated. His health was normal till 2017. Thereafter again cancer spread into bones and

lower limbs. He was referred to RML IMS, Lucknow wherein chemotherapy was given alongwith

Zolendronic injection. The following claims were submitted out of which claim for Rs.79,232/-,

Rs.97,153/-, Rs.80,918/- and Rs.1,02,441/- were repudiated :

Claim No.

& Date

Date and Time of

Admission

Date & Time of

Discharge

Amount Status

1/19423117 08.04.2019 05.02.2019 12.00 noon 05.02.2019 20.31 pm Rs.132297.00 Paid

2/not allotted 16.04.2019 16.04.2019 Rs.82410.00 Pending

3/19691765 14.05.2019 10.00 a.m. 14.05.2019 13.00 pm Rs.66,736.00 Paid

4/20051191 12.06.2019 10.00 am 12.06.2019 13.30 pm Rs.135510.00 Pending

5/20207730 10.07.2019 09.00 am 10.07.2019 13.00 pm Rs.78717.00 Pending

6/20446808 08.08.2019 09.30 am 08.08.2019 01.30 pm Rs.106917.00 Pending

7/MD5353382 05.11.2019 09.00 am 05.11.2019 13.00 pm Rs.73232.00 Repudiated

8/MD5409349 03.12.2019 10.30 am 03.12.2019 15.26 pm Rs.97153.00 Repudiated

9/MD5495376 04.01.2020 12.21 pm 05.01.2020 14.11 pm Rs.80918.00 Repudiated

10/MD5572933 03.02.2020 13.41 pm 04.02.2020 14.14 pm Rs.102441.00 Repudiated

Although claim for Rs.Rs.1,32,297/- and Rs.66,736/- were paid. Repudiation was made on the

following grounds :

“We regret to inform you that your claim could not be considered for payment due to the following

reasons and stands as repudiated :

Policy Condition No. with description : As evident from the claim documents injection Zolendronic

acid was administered. The policy covers parenteral administration of chemotherapeutic agents

only. Zoledronic acid is not not cancer chemotherapy drug but supportive treatment in cancer hence

not covered as a day-care procedure (note:procedures/treatments usually done in outpatient

departments are not payable under the policy even if converted as in-patient in the hospital for more

than 24 hours. Clause No:4.7

Detailed Narration : Charges incurred at hospital or nursing home primarily for diagnosis x-ray or

laboratory examinations or other diagnostic studies not consistent with or incidental to the

diagnosis and treatment of positive existence of presence of any ailment sickness or injury for which

confinement is required at a hospital/nursing home unless recommended by the attending doctor.”

Respondent’s representative submits that claim was repudiated for the reasons that it is not

covered under the chemotherapy. It is further submitted that the hospitalization was for less than

24 hours. Accordingly as per Condition No:2.19 of the policy bond, it cannot be paid. Clause 2.19 of

the policy bond reads as under :

“Hospitalization means admission in a hospital/nursing home for a minimum period of 24 in-patient

care consecutive hours except for the specified day care procedures/treatments, where such

admission could be for a period of less than 24 consecutive hours. (Note: Procedures/treatments

usually done in outpatient departments are not payable under the policy even if converted as in-

patient in the hospital for more than 24 hours.)”

It is further submitted that the treatment is not covered under the head Chemotherapy under

Clause No:3.14 of the policy bond.

Undoubtedly, hospitalization of the complainant was for less than 24 hours in RML IMS,

Gomtinagar, Lucknow. This institute is a Government Institute. Treatment undertaken at the

Government institute cannot be put to doubt.

During the course of hearing, a query was raised as to whether hospitalization although for less

than 24 hours was necessary or not? Dr.Madhup Rastogi, MD, Professor & Head, Department of

Radiation Oncology, Dr. RMLIMS, Gomtinagar, Lucknow issued the claim form Part B on 07.08.2021

with following remarks :

“It was necessary to hospitalize for administration of Zoledronic acid and other electrolytes some

times for more than 24 hours otherwise 4 to 6 hours depending upon the condition of patient.”

In the repudiation also it is mentioned that charges incurred at hospital or nursing home primarily

for diagnosis x-ray or laboratory examinations or other diagnostic studies not consistent with or

incidental to the diagnosis and treatment of positive existence of presence of any ailment sickness

or injury for which confinement is required at a hospital/nursing home unless recommended by the

attending doctor.

It is not in dispute in the repudiation letter which is for an amount of Rs.97153/- that Zolendronic

acid is a supportive treatment in cancer. It shows that respondents are also not challenging that the

drug is not to be used in cancer treatment. Doctor certified the admission to administer the drug

although for less than 24 hours, drug is necessary for the ailment being suffered by the complainant.

In such circumstances, repudiation made by the respondent could not stand test of law as well as

policy bond. Accordingly, repudiations are quashed. Respondents are directed to make the

payment of the claims as per terms and conditions of the policy bond.

Order :

Complaint is allowed with direction to the respondents to make payment of claim as per terms and

conditions of the policy bond within a period of 30 days. Some claims are still pending which should

also be disposed off within a period of 30 days in view of the directions given in the body of the

judgement.

22. Let copy of award be given to both the parties.

Dated : August 12, 2021 Justice(Retd.) Anil Kumar Srivastava

Place : Lucknow Insurance Ombudsman

OFFICE OF INSURANCE OMBUDSMAN

MUMBAI & GOA

METROPOLITAN REGION EXCLUDING NAVIMUMBAI & THANE

(Under Rule No. 16/17 OF Insurance Ombudsman Rules 2017)

OMBUDSMAN : SHRI VINAY SAH

CASE OF COMPLAINANT -Mr.Rajendra M. Khandelwal

VS

RESPONDENT : The Oriental Insurance Co. Ltd.

COMPLAINT REF: NO:MUM-H-050-2122-0006

AWARD NO: IO/MUM/A/HI/ /2021-2022

VIRTUAL HEARING

1 Name & Address of the

Complainant

Mr.Rajendra M. Khandelwal

Mumbai

2 Policy No:

Type of Policy

Duration of Policy/Period

Floater Sum Insured

131102/48/2019/3985

PNB Oriental Group Mediclaim policy

04/10/2018 to 03/10/2019

Rs.5,00,000/-

3 Name of Insured

Name of the policy holder

Rajendra M. Khandelwal

Mridula R. Khandelwal

4 Name of Insurer The Oriental Insurance Co. Ltd.

5 Date of Repudiation 16.01.2020

6 Reason for repudiation Pre-existing disease

7 Date of receipt of the complaint 24.02.2021

8 Nature of complaint Total repudiation of claim

9 Amount of claim Rs.8,87,098/-

10 Date of Settlement …………..-……………

11 Amount of relief sought Rs.4,50,673/-

12 Complaint registered under Indian

Ombudsman Rules 2017

13 (b)

13 Date of Hearing 29.07.2021 @ 11.15 am


a) For the complainant Mr.RajendraKhandelwal

b) For the insurer Ms. Sylvia Vaz/Dr.Komal



Brief Facts of the Case :The Complainant is covered along with his spouse for sum insured

Rs.5,00,000/- since 04/10/2016 under PNB Royal Mediclaim Policy. Mr.Rajendra M.

Khandelwal was admitted at Asian Heart Institute from 01/09/2019 to 17/09/2019 for the

treatment of IHD, Triple vessel coronary artery disease with Diabetes Mellitus. His claim of

Rs.4,50,673/- was repudiated by the Company on the ground of pre-existing disease. The

Complainant is not agreeable with the said decision.

Contentions of the Complainant: The Complainant submitted that he was admitted at Asian

Heart Institute for Coronary Artery Bypass grafting surgery and lodged the claim with the

Company. The Company repudiated his claim on the ground of pre-existing disease of

Diabetes since 30 years, Chronic Obstructive Pulmonary disease since 7 years, Gastro

esophageal reflux disease, allergic rhinitis and ex-smoker who quit smoking in 2013. He added

that the Company had been repeatedly replying that due to associated risk factors of diabetes

mellitus and smoking- both being pre-existing ailments. However,the respondent couldn't

provide the proof or documentary evidence to justify scientifically that his IHD condition i.e.

built up fats, cholesterol and other substances in and on the artery wall was only due to

diabetes and smoking which was stopped over 7 years ago (i.e. in Jan 2013). He further added

that he was an occasional smoker, never daily or regular or chain smoker in the past and

stopped totally since Jan. 2013. He stated that his diabetes basically hereditary from his

mother’s side which has been well under control and in absence of any conclusive proof, the

rejection of claim is only on vague assumption . Reports suggest and even protein which we

consume daily in our regular meals like wheat, pulses, fruits, vegetables, non-veg good etc.

can cause blocked arteries. Not to mention about consumption of oils, butter, ghee, cheese

fried/deep fried goods one consumes on regular basis in day to day life can also cause this

physical trouble.

Therefore,the stand taken by the Company is not acceptable to him as his present IHD

condition is not pre-existing in nature.

Contentions of the Respondent: The Respondent submitted that Mr.Rajendra M. Khandelwal

was admitted for Ischemic Heart Disease, Triple vessel coronary artery disease with Diabetes

Mellitus, Chronic Obstructive Pulmonary disease, Allergic Rhinitis, and Urinary Tract Infection

– Klebsiella Pneumonia in Asian Heart Institute from 01/09/2019 to 17/09/2019 and treated

for the same. As per Hospital Discharge summary and available details patient is a known case

of Diabetes since 30years, Chronic Obstructive Pulmonary disease since 7 years, Gastro-

esophageal reflux disease, allergic rhinitis and ex-smoker who quit smoking in 2013. His was

a case of burning sensation over the chest on walking since 2-3 months with pain radiating to

the jaw since 2-3 months which was relieved on rest. He was advised Coronary Angiography

which was done on 5/8/19 which revealed Triple Vessel Disease. He was then advised

Coronary Artery Bypass Graft surgery (CABG) and underwent CABG x 3 grafts on 3/9/2019.

Claim was denied and repudiated as the date of inception of policy is 04/10/16 and the

ailment is pre-existing to the policy. This is the third year of the policy. The insured’s coronary

artery condition is due to associated risk factors of Diabetes and smoking both of which are

Pre-existing. As per policy terms & conditions pre-existing diseases are not admissible during

first 36 months of the policy. Hence, this claim stood non-payable under exclusion clause

4.1 - All Pre-existing Disease (whether treated/ untreated, declared or not declared in the

proposal form), are excluded upto 36 months of the policy being in force. Pre-existing

diseases shall be covered only after the policy has been continuously in force for 36 months.

For the purpose of applying this condition, the date of inception of the first PNB-Oriental

Royal Mediclaim policy shall be considered, provided the renewals have been continuous and

without any break in the policy period. This exclusion shall also apply to any complication(s)

arising from preexisting diseases. Such complications will be considered as part of the

preexisting health condition or disease.

Forum’s Observations/Conclusion: On perusal of the documents produced on record, it is

observed that the claim in respect of treatment for CABG undergone by Mr.Rajendra M.

Khandelwal was lodged in the third year since inception of the policy with the Respondent

and the policy has 36 months waiting period for pre-existing disease. The Complainant’s

Coronary Artery condition is due to associated risk factors of Diabetes which is pre-existing as

per Hospital Discharge Summary (since 30 years). There are many causes for Coronary Artery

Disease including Diabetes which is associated risk factor. Thus in order to arrive at a fair

decision the Forum obtained independent medical opinion from Dr.BrajeshKunwar, MD, DM

(Cardiology), FESC, FSCAI (Senior consultant Cardiologist) which reads as “I have seen all the

documents appended and observe that the insured patient, k/c/o diabetes mellitus has

been diagnosed with IHD, Triple Vessel Disease on Angiography and has undergone off

pump CABG for the same. Regarding whether the Diabetes is the sole cause for CABG, I

opine that Yes. Diabetes is a very strong risk factor for IHD and IHD has progressed to TVD

for which CABG was performed. CABG is attributed to his diabetic history.”

Based on above medical opinion and as per indoor case papers of the hospital patient is a

known case of Diabetes since 30years, Chronic Obstructive Pulmonary disease since 7 years,

Gastro- esophageal reflux disease, allergic rhinitis and ex-smoker who quit smoking in

2013,the Company’s stand of denial of claim on the ground of Policy Exclusion Clause 4.1 is

sustainable.

Though the Forum is able to appreciate the concern of the complainant in this regard, it has

also to be borne in mind that whenever any dispute arises, it is settled based on the terms &

conditions of the policy under which a claim has arisen since these form the very basis of the

contract between the parties. The Forum, therefore, does not find any valid ground to

intervene with the same and pass the following Order.

AWARD

Under the facts and circumstances of the case, the complaint lodged by Mr.Rajendra M.

Khandelwal against The Oriental Insurance Co. Ltd. does not sustain.

It is particularly informed that in case the award is not agreeable to the complainant, it would

be open for him/her, if he/she so decides to move any other Forum/Court as he/she may

consider appropriate under the Laws of the Land against the Respondent Insurer.

Dated: This 05th day of August, 2021 at Mumbai.

(VINAY SAH)


MUMBAI & GOA

METROPOLITAN REGION EXCLUDING NAVI MUMBAI & THANE

(Under Rule No. 16/17 of Insurance Ombudsman Rules 2017)

OMBUDSMAN: SHRI. VINAY SAH

CASE OF COMPLAINANT - MR NARENDER PANJWANI

VS

RESPONDENT: HDFC ERGO GENERAL INSURANCE COMPANY LIMITED

COMPLAINT REF: NO: MUM-H-018-2122-0093


VIRTUAL HEARING


Complainant

MrNarenderPanjwani

Mumbai

2 Policy No:

Type of Policy


1) 120100/22001/2018/A016900/324 (PA)

2)120100/12586/2018/A016898/389 (Health)

3)120100/12586/2018/A016898/424 (Health)

Group P A and Group Assurance Health Plan

(1) & (2) 12.09.2019 to 11.09.2020 (3) 06.10.2019 to 05.10.2020

3 Name of the policyholder 1.

MrNarenderPanjwani&MrsArchanaPanjwani

2. MrNarenderPanjwani

3 – MsArchanaNarenderPanjwani

4 Name of Insurer Apollo Munich Health Insurance


6 Reason for repudiation --


8 Nature of complaint Non Renewal of policies

9 Amount of claim --

10 Date of Partial Settlement --

11 Amount of relief sought --

12 Complaint registered under The

Insurance Ombudsman Rules 2017

13 (f)

13 Date of Hearing 17.08.2021


a) For the complainant MsChandniPanjwani

b) For the insurer MrNeerajShivangikar, Asstt Vice President-

Legal claims



Brief Facts of the Case: The complainant and his spouse were covered under Respondent's

Group Health Policy under two different policies, the effective dates were from 12.09.2019

to 11.09.2020 and 06.10.2019 to 05.10.2020 respectively. They were also covered under

Respondent's Group P A policy from 12.09.2019 to 11.09.2020. Those Group policies were

issued by the Respondent through Canara Bank to their account holders. The Complainant

had been holding the subject policies for the last six years and the premium of those policies

were made by the auto-debit facility from the bank account of MrNarenderPanjwani.

However,at the time of renewal of those policies on 11.09.2020 and 05.10.2020, there was

no auto-debit and the policies of MrPanjwani and his wife were not renewed. The

Complainant requested HDFC ERGO ( as Apollo Munich had merged with HDFC ERGO) for

renewal but HDFC disagreed to renew the policies. Aggrieved by denial of renewals by the

Respondent, the Complainant approached the Forum for reinstatement of the aforesaid

policies.

Contentions of the Complainant: The Complainant submitted that he had availed three

policies through an intermediary, Canara Bank and had been paying premium each year for

the past six years through auto-debit to Apollo Munich Health insurancefor renewal of the

policies. At the time of 2020-21 renewal of these policies, Canara Bank did not auto debit

Complainant’s account as Apollo Munich was merged with HDFC ERGO General Insurance

Company. The Complainant stated that this was a serious lapse on the part of the insurers as

he was not approached by the Respondent for renewal/instructions to follow for the same of

those insurance policies. The result was that he was left without any insurance cover. The

Complainant contended that he was a senior citizen of 71 years and it was going to be

extremely difficult and expensive for him to go in for fresh insurance covers. The Complainant

pointed out that he wrote to HDFC ERGO as also their grievance cells requesting them to

reinstate his policies but HDFC ERGO declined his request. The complainant submitted that

he was not at fault and hence,requested the Forum to intervene for reinstatement of all the

three policies.

Contentions of the Respondent: It was contended on behalf of the Respondent that the

Insured, being a customer of Canara Bank which was a Group policyholder of the Company,

had taken a tailor-made Health Group Insurance Plan which was offered only to the existing

customers of Canara Bank. As the same was a Tailor-made Policy, its terms and conditions

were duly agreed by the Master Policyholder i.e. Canara Bank and thereupon the Premium

was fixed. The Respondent further submitted that Canara Bank, on April 20 had decided to

discontinue the Renewal of members under the Group Assurance Health Plan Master Policy

No 120100/12586/2018/A016898 and Group Personal Accident Insurance Master Policy No.

120100/22001/2018/A016900. Hence, respondent company communicated to Canara Bank

to inform all policyholders about policy discontinuation and Canara Bank had posted a public

notice on its website about Group Assurance Health Plan discontinuation. Canara Bank also

informed policyholders that they could renew their policies with existing general insurance

partners, Bajaj Allianz GIC and TATA AIG. The Respondent submitted a copy of the notice

dated 13.04.2020 in support of the same. The Respondent further stated that they had

responded to the complainant from their grievance cell on 11.02.2021. In view of

Product/Policy/Group policy arrangement had already been discontinued by CanaraBank,as

a result of which, such policy issuance under those products was not available now.

Respondent further stated that portability into their retail product was allowed subject to

underwriting evaluation & approval within the grace period of 30 days. However, no

portability request was received regarding the said policies within 30 days of expiry of the

policy. Therefore, the respondent concluded that the portability or renewal of the policies

was not feasible.

Forum’s Observations/Conclusion: The Forum, after hearing the deposition of both the

parties to the dispute, noted that the Complainant was holding following three policies with

the Respondent.

Policy Number Product Insured Name Policy period

120100/12586/2018/A016898/389 Group Assurance

Health Plan

MrNarenderPanj

wani

12/09/2019 to

11/09/2020

120100/12586/2018/A016898/424 Group Assurance

Health Plan

MrsArchanaPanj

wani

06/10/2019 to

05/10/2020

120100/22001/2018/A016900/324 Group Personal

Accident

MrNarenderPanj

wani and

MrsArchanaPanj

wani

12/09/2019 to

11/09/2020

It appears that the subject Group policies were issued by the Respondent through Canara

Bank to their account holders. In April 2020, Canara Bank shifted those Group Policies to

other insurers. The public notice was put up by the Bank stating the withdrawal of Group

Plan by HDFC Ergo (Erstwhile Apollo Munich Health Insurance Co.) to the customers for

renewals beyond 14.04.2020 and suggested renewal of the policies with their new partners

and therefore,requested the customers to contact their nearest branch for the same. In this

connection, it is observed that Complainant had missed out on this notice and the policies

obtained by them having expiry dates of 11.09.2020 and 05.10.2020 were not renewed by

them. In the instant case, since the subject policies were discontinued and not existing with

the Respondent, the Complainant could have opted for any of the available individual

health/PA covers with the Respondent. However, these alternative individual covers would

not have the benefit of discounted premium like the subject Group Policies availed earlier by

the Complainant. Besides,the insured being a Senior Citizen,it would be difficult for them to

shift to individual covers with substantial higher rate of premium. Hence,to get the similar

benefits of the subject Group Policy, Complainant can approach Canara Bank for renewal of

those policies under Banker’s new insurer partner. Given the facts, the Forum has no ground

to intervene with the decision of the Respondent and the complaint filed by the complainant

is not sustainable.

AWARD

Under the facts and circumstances of the case, the complaint lodged by

MrNarenderPanjwani against HDFC Ergo General Insurance Company Limited does not

sustain.

It is particularly informed that in case the award is not agreeable to the complainant, it would



Dated: This 31st day of August, 2021 at Pune.

(VINAY SAH)

INSURANCE

OMBUDSMAN


MUMBAI & GOA




CASE OF COMPLAINANT - MRS KAVITA PRAKASH BHEDA

VS

RESPONDENT: UNITED INDIA INSURANCE CO. LTD.



VIRTUAL HEARING

1 Name & Address of the Complainant MrsKavitaPrakashBheda

Mumbai

2 Policy No:

Type of Policy


Sum Insured

0504002820P102561452

AB Arogyadaan Group Health Insurance Policy

09.06.2020 to 08.06.2021

Rs.5,00,000/-

3 Name of Insured


MrPrakashBheda

MrsKavitaPrakashBheda

4 Name of Insurer United India Insurance Co. Ltd.


6 Reason for repudiation Clause 3.23 – OPD treatment


8 Nature of complaint Reimbursement

9 Amount of claim Rs.49,894/-


11 Amount of relief sought Rs.49,894/-

12 Complaint registered under The

Insurance Ombudsman Rules 2017

13 (b)



a) For the complainant MrParthikBheda

b) For the insurer MsHema Florence Gode, A.O.



Brief Facts of the Case: Complainant, MrsKavitaBheda’s spouse was tested Covid-19 positive, and as advised by the treating doctor was home quarantined from 18.09.2020 to 02.10.2020. The complainant approached this Forum with a complaint against denial by the Respondent United India Insurance Co. Ltd. of a claim lodged under the policy for the said treatment on the ground that treatment done on an OPD basis, hence was not payable under Clause 3.23 of the policy terms and conditions.

Contentions of the Complainant: The Complainant’s son, MrParthikBheda appeared and

deposed before the Forum. He submitted thathis father was detected with COVID 19 positive

on 18.09.2020 and was home quarantined as advised by the treating doctor in a rented room

of their society. During the period from 18.09.2020 to 02.10.2020, all the treatments were

made to him on the advice of a treating doctor on phone and Whatsapp messages due to the

Corona Pandemic situation. The complainant hence stated that they dIdnot have any daily

progress reports nor treatment records by doctors. He added that they had claimed only for

the various investigation reports prescribed by the treating doctor and for the expenses

incurred for the medicines. In respect of the subject claim, initially Respondent raised query

for non-submission of daily progress report and treatment records. Subsequently rejected the

claim stating the treatment availed on an OPD basis was not payable under policy terms and

conditions. The Complainant argued that due to Janata curfew, the doctor never visited their

place and they were not able to produce any such documents as required by the Respondent.

However, Complainant submitted a treating doctor's letter confirming the insured patient

being Home Quarantined for Covid Treatment. Based on the facts, the Complainant not

agreeing with the reason cited by the Respondent for denial of the subject claim requested

the Forum to intervene in the settlement of the claim amount.


Complainant was covered with the spouse for floater Sum Insured of Rs.5,00,000/- under

Tailormade Group Mediclaim Policy issued to Andhra Bank account holders. The

Complainant reported a reimbursement claim for Home Quarantine Covid Treatment of her

husband MrPrakash T Bheda between 07.09.2020 and 21.09.2020. The Respondent further

stated that the Complainant had claimed all the expenses in respect of diagnostic

tests/medicines including her non-insured family members. Since the treatment taken was

on an outpatient basis, the subject claim was rejected as the same is not covered under

policy conditions no.3.23 which states that HOSPITALISATION means admission in a

hospital for a minimum period of twenty-four (24) consecutive 'In-patient care' hours

except for specified procedures/treatments, where such admission could be for a period

of less than twenty-four (24) consecutive hours.

Note; Procedures/treatments usually done in the outpatient department are not payable

under the policy even if admitted/converted as an in-patient in the hospital for more

than 24 hours." The Respondent added that the treatment could not be considered under

Home Care treatment as Daily Progress notes with treatment records by treating doctor and

nurses and daily vital charting were not available in this case which is mandatory for Covid

19 Home care Treatment as per the guidelines issued by Respondent's Head Office Circular

No. HO/Health/CIR/10/2020- 21 dated 7/07/2020. Further Respondent pointed out that the

letter issued by the treating doctor stated the insured patient's treatment was w.ef.

18.09.2020 whereas the complainant had submitted bills from 02.09.2020. Based on the

aforesaid facts, the Respondent stood by their decision of denial of the claim being made as

per policy terms and conditions.

Forum’s Observations/Conclusion: Onscrutiny of the documents produced on record and

depositions made by both the parties, it is observed that during the Covid pandemic,

Respondent had issued special guidelines for the settlement of Home Care treatment

availed by the Insured Person at home for Covid-19 on a positive diagnosis of Covid-19 in a

Government-authorized diagnostic Centre, which in normal course would require care and

treatment at a hospital but is taken at home maximum of up to 14 days per incident.

Respondent contended during the hearing that though initially claim was rejected on the

ground of hospitalization clause of the policy, as per the subsequent Home Care guidelines,

due to non-submission of daily treatment records of the insured patient, they could not

settle the subject claim. In view of the same, Forum directed the Complainant to forward

the screenshots of the treatments prescribed by the treating doctor through WhatsApp

messages. The Complainant accordingly forwarded all the prescriptions advised by the

treating doctor and communications made by him through WhatsApp calls. The same was

scrutinized and it was noted that DrMitesh Gala had treated the insured patient during the

insured patient’s home quarantined period from 18.09.2020 to 02.10.2020 prescribing

requisite investigations and medications. In the instant case, it should be noted that the

insured patient is a Senior citizen and holding the policy with the Respondent for the last ten

years. Further, the submission of treating doctor’s prescriptions and communications made

through WhatsApp confirms the patient's treatment during his home quarantine period in

addition to the certificate issued by the treating doctor. Hence taking into account the

difficult situation during the covid period and considering the screenshots provided by the

Complainant of the communications/prescriptions made by the treating doctor through

WhatsApp messages as the line of treatment of the insured patient, Respondent is directed

to pay the admissible amount barring non-medicals if any on Home Care Treatment of

MrPrakashBheda as per policy terms and conditions. Thus, the decision of the Respondent

is intervened by the following order:

AWARD

Under the facts and circumstances of the case, United India Insurance Company Limited is

directed to pay the admissible amount less non-medicals ,if any, under claim

ID:201100143829 to the Complainant, MrsKavitaPrakashBheda towards a full and final

settlement of the complaint within 30 days from the issuance of the award to avoid penal

interest as per guidelines of the IRDAI and inform the payment particulars to this Forum.

There is no order for any other relief. The case is disposed of accordingly.


of the Insurance Ombudsman Rules, 2017:

a) As per Rule 17(6) of Insurance Ombudsman Rules, 2017, the insurer shall comply with

the award within thirty days of the receipt of the award and intimate compliance of

the same to the Ombudsman.

b) As per Rule 17(8), the award of the Insurance Ombudsman shall be binding on the

Insurers.

c) It is particularly informed that in case the award is not agreeable to the complainant,

it would be open for him/her, if he/she so decides to move any other Forum/Court as

he/she may consider appropriate under the Laws of the Land against the Respondent

Insurer.


(VINAY SAH)

INSURANCE

OMBUDSMAN


MUMBAI & GOA




CASE OF COMPLAINANT - MS.ASHALATA. B. PATIL

.V/S

RESPONDENT: ORIENTAL INSC.CO. LTD.



VIRTUAL HEARING


Complainant

Ms.Ashalata B Patil

2 Policy No:

Type of Policy


Sum Insured

131102/48/2021/2047

PNB- Oriental Mediclaim Policy 2017 (Group)

08.07.2020 to 07.07.2021

Rs.5,00,000/-

3 Name of Insured


Ms.Ashalata B Patil

4 Name of Insurer The Oriental Insurance Co.Ltd.

5 Date of Partial Repudiation --

6 Reason for partial repudiation --


8 Nature of complaint Policy renewed without continuity benefit

9 Amount of claim --


11 Amount of relief sought --

12 Complaint registered under RPG

rules

13 (f)



a) For the complainant Mr BhagwantPatil

b) For the insurer Ms Sylvia Vas, Asstt Manager



Brief Facts of the Case: The complainant and her spouse were covered under PNB-ORIENTAL

Group Mediclaim policy -2017 issued to Bank account holders of PNB. The Complainant is

holding the subject policy since 15.05.2014 for a Sum Insured of Rs.5,00,000/-. Last year at

the time of renewal of the policy in May 2020, due to lockdown and the insured being a senior

citizen could not go out and pay the renewal premium. She managed to pay the renewal

premium to the Bank on 08.07.2020. The Complainant received the renewed policy with

effect from 08.07.2020 however, the policy was issued as a fresh policy without allowing any

continuity benefit to them. The Complainant approached the Forum, requesting to intervene

in the matter and allow continuity benefit under the subject policy treating same as

continuous renewal, as she could not issue the premium cheque due to genuine reason of

lockdown.

Contentions of the Complainant: Complainant’s spouse, Mr BhagwantPatil appeared and

was deposed before the Forum. He submitted that they had availed PNB-ORIENTAL

Mediclaim policy through Punjab National Bank issued to account holders of the bank. The

said policy was continuously renewed with the Respondent since May 2014. However, at the

time of policy renewal on 14.05.2020, there was a lockdown, and being a Senior Citizen,they

could not go out of the house due to the Corona pandemic situation. On situation getting

little stable, he made renewal premium payment on 08.07.2020 to Punjab National Bank,

Ghatkopar ( East ) branch. The renewed policy was issued with effect from 08.07.2020 to

07.07.2021 without giving any continuity benefit under the subject policy. The Complainant

not agreeing with the policy issued as fresh without allowing continuity benefit, requested

the forum to treat the renewal of subject policy as a continuous renewal.


insured aged 69 years was covered with her spouse aged 81 years with the Respondent since

15.05.2014 for Sum Insured of Rs.5,00,000/- under PNB Royal Group Mediclaim Policy. The

Complainant's policy was due for renewal on the 15th of May 2020. During this time due to

lockdown, all officials of the Company were working from home and all the renewals were

done by sending links to the customers, NEFT transactions, online renewals, etc. In the

subject case, Respondent received renewal instructions from the insured, Mrs AshalataPatil

on 08.07.2020 through Punjab National Bank after the 30 days of grace period for renewals

as allowed by IRDA. Hence the policy was renewed as a fresh policy and continuity benefit

was not allowed under the subject policy as per policy terms and condition 5.3(ii) which reads

as "In the event of delay in renewal of the Policy, a grace period of 30 days is allowed.

However, no coverage shall be available during the grace period and any disease/Injury

contracted during the break period shall not be covered and shall be treated as Pre-existing

disease.”

Forum’s Observations/Conclusion: Onscrutiny of the documents produced on record and

deposition made by both the parties, it is observed that Respondent had issued a fresh policy

to the Complainant without allowing continuity benefit due to delay in payment of renewal

premium by the Complainant after a gap of 55 days. However, in the instant case, it is noted

that the insured is a Senior Citizen and hence could not pay the renewal premium in May 2020

due to restrictions of the covid situation. Moreover, it is also observed that the premium for

all earlier renewals had been paid by him on time. Considering these facts and also during

the covid situation, IRDAI had permitted Insurers, the relaxation of grace period in case of

renewal of health insurance policies, Forum directs the Respondent to condone the delay

without deeming such condonation as a break in the policy subject to no coverage shall be

available during the gap period and any disease/Injury contracted during the break period

shall not be covered and shall be treated as Pre-existing disease. The decision of the

Respondent is intervened by the following order:

AWARD

Under the facts and circumstances of the case, Oriental Insurance Company Limited is

directed to grant continuity benefit under Policy No.131102/48/2021/2047 issued to the

Complainant, Ms Ashalata B Patil, treating the policy as renewal subject to no coverage

shall be available during the gap period and any disease/Injury contracted during the break

period shall not be covered and shall be treated as Pre-existing disease, towards a full and

final settlement of the complaint within 30 days from the issuance of this order.



a) As per Rule 17(6) of Insurance Ombudsman Rules, 2017, the insurer shall comply with

the award within thirty days of the receipt of the award and intimate compliance of

the same to the Ombudsman.

b) As per Rule 17(8), the award of the Insurance Ombudsman shall be binding on the

Insurers.

c) It is particularly informed that in case the award is not agreeable to the complainant,

it would be open for him/her, if he/she so decides to move any other Forum/Court as

he/she may consider appropriate under the Laws of the Land against the Respondent

Insurer.



MUMBAI & GOA


(Under Rule No. 16/17 of Insurance Ombudsman Rules, 2017)

OMBUDSMAN :MR VINAY SAH

CASE OF COMPLAINANT - MRVIJAY SMERCHANT

VS

RESPONDENT :THE NEW INDIA ASSURANCE CO LTD



1 Name & Address of the Complainant Mr Vijay S Merchant Mumbai 400 053

2 Policy No: Type of Policy Duration of Policy/Period Sum Insured

71250034192100000012 Good Health Group Mediclaim Policy 01.10.2019 - 30.09.2020 Rs.5,00,000/- CB 30%

3 Name of Insured Name of the policy holder

MrVijay S Merchant - do -

4 Name of Insurer The New India Assurance Co Ltd


6 Reason for repudiation No active line of treatment


8 Nature of complaint Total repudiation of claim

9 Amount of claim 1) Rs.88,984/-

10 Date of Partial Settlement -

11 Amount of relief sought Rs.88,984/-

12 Complaint registered under Insurance Ombudsman Rules 2017

Under Rule 13(b)

13 Date of Hearing 26.08.2021 at 12 pm (Virtual Hearing)


a) For the complainant MrVijay S Merchant

b) For the insurer MrCBTarun Jai, Assistant Manager



Brief Facts of the Case :Complainant,Mr Vijay SMerchant,78 years old wasadmitted to

Nanavati Super Speciality Hospital, Mumbai on 31.12.2019 with complaints of breathlessness

for 2 weeks and was diagnosed with Anemia,k/c/o DM and Multiple Antral Ulcers. He

underwent Upper GI Endoscopy which was done under pulse oximeter monitoring after giving

pharyngeal xylocaine spray, given blood transfusionand discharged on04.01.2020. He

approached this Forum with a complaint against thetotal repudiation by the Respondent, The

New India Assurance Co Ltd of a claim lodged under the policy for the said hospitalization.

Contentions of the complainant :The complainant appeared and deposed before the Forum.

He contendedthat hepreferred a claim with the Insurance Cofor Rs.88,984/- which was

repudiated under Exclusion Clause 4.4.8 stating that no active line of treatment was

administered and multiple investigations and blood transfusion were only done.He submitted

that during the hospital treatment he was given 3 bottles blood and other treatment.He

furnished the treating doctor’s certificate dt.01.09.2020 which states that he had severe

anaemiaof HB 4.8 gmswith Multiple Antral Ulcers andDiabetes. Hence, he required blood

transfusion which definitely required hospitalization for his management. The complainant

grieved that he was not agreeable to the claim repudiation and hence requested for the

settlement of his genuine claim.

Contentions of the Respondent:It was contended on behalf of the Respondent that the

claimant had complaint of breathlessness for 2 weeks. He was diagnosed with Anemia with

UGI Endoscopy.s/o with multiple Antral Ulcer with k/c/o/ DM. The investigation further

revealed that the Insured was having bleeding due to multiple Antral Ulcers. Hence Upper GI

Endoscopy procedure was carried out. Further, during the course of hospitalization blood

transfusion was performed. On scrutiny of the claim documents it was observed that the

treatment given does not support the need for hospitalization. Further, Company submitted

the medical opinion of their panel doctor who has also agreed towards the repudiation of the

claim. Hence,the claim was repudiated as per terms and conditions of Good Health Group

Mediclaim as per Clause 4.4.8 which read, “Charges incurred at Hospital or Nursing Home

primarily for diagnosis, X ray or Laboratory examinations or other diagnostic studies not

consistent with or incidental to the diagnosis and treatment of positive existence or

presence of any ailment, sickness or injury, for which confinement is required at a

Hospital/Nursing Home.”

Forum’sObservations/Conclusion:The online hearing of the above case was held on

26.08.2021 at 12.00 p.m. through GotoMeet App to resolve the referred dispute. The Forum

observed that medical necessity was obvious keeping in mind the age of the complainant,

aged 78, with h/o complaints of breathlessness since 2 weeks, anorexia, stools passing

intermittently and severe anaemia. The Endoscopy UGI showed presence of Multiple Antral

Ulcers. The treating doctor, DrNitinRathod has stated in his certificate that the patient

suffered severe anaemia, hence needed blood transfusion for which hospitalization was

definitely needed for his management. The Forum opined that it is for the doctor to decide

what treatment to be given and whether hospitalization is necessary or not. The medical

policy pays for medically necessary and reasonable hospitalization and in the instant case it

was necessary that the patient was required to be admitted. Any treatment given in a hospital

whether oral or intravenous is payable as per policy terms and conditions. Therefore, the

hospitalization cannot be said to be totally unwarranted and solely for diagnostic

purposesince the complainant had Multiple Antral Ulcers and investigation was needed to

decide the further course of treatment. Most importantly it was advised by the doctor. The

Forum, hence, directed the Respondent to pay Rs.88,984/-, deducting the non-payables, if

any, to the complainant. Hence the Respondent’s decision is intervened by the following

Order :

AWARD

Under the facts and circumstances of the case, TheNew India Assurance Co Ltd is directed

to pay Rs.88,984/-barring non-payables, if any, in favor of the complainant, towards full

and final settlement of the complaint, within 30 day from issuance of this order so as to

avoid penal interest as per guidelines of the IRDAI. There is no order for any other relief.

The case is disposed of accordingly.



a) As per Rule 17(6) of Insurance Ombudsman Rules, 2017, the insurer shall comply with the award within thirty days of the receipt of the award and intimate compliance of the same to the Ombudsman.

b) As per Rule 17(8) the award of Insurance Ombudsman shall be binding on the Insurers. It is particularly informed that in case the award is not agreeable to the complainant, it would



Dated: This 2nd day of September, 2021 at Pune.

(VINAY SAH)

INSURANCE OMBUDSMAN


MUMBAI & GOA



OMBUDSMAN: MR VINAY SAH

COMPLAINANT:MRSRENU WADHWA

VS

RESPONDENT: THE NEW INDIA ASSURANCE COLTD



1 Name & Address of the Complainant

MrsRenuWadhwa Mumbai 400 031

2 Policy No: Type of Policy Duration of Policy/Period Sum Insured

14250034190400000050 New IndiaFlexi Floater Group Mediclaim Policy 11.11.2019 to 10.11.2020 Rs.5,00,000/-

3 Name of Insured Name of the policy holder

MrsRenuWadhwa - do -

4 Name of Insurer The New India Assurance Co Ltd

5 Date of Repudiation -

6 Reason for repudiation -


8 Nature of complaint Product withdrawn and no intimation for increase in premium

9 Amount of claim -

10 Date of Partial Settlement -

11 Amount of relief sought -

12 Complaint registered under Ombudsman Rules, 2017

Under Rule 13/1(f)

13 Date of Hearing 17.08.2021at 04.15 pm (Virtual Hearing)


a) For the complainant Not represented

b) For the insurer MsVandanaJathan, Administrative Officer



Brief Facts of the Case :The complainant MrsRenuWadhwa, aged 69 years was covered under

New India Flexi Floater Group Mediclaim (PNB) Policy bearing No. 14250034190400000050

for the period from 11.11.2019 to 10.11.2020 for Sum Insured (SI) of Rs.5las with yearly

premium of Rs.10,251/-. In the month of November, 2020, sheapproached Punjab National

Bank (PNB) to pay the renewalpremium due 11.11.2020, the bank official informed her that

The New India Assurance Company has withdrawn the product and offered other alternative

policies of The Oriental Insurance Company, Bajaj Allianz Insurance Co Ltd or any other

insurance companies. The complainant submitted that she was not aware of this and came

to know only when she approached PNB to pay the renewal premium.Hence she approached

this Forum for justice.

Contentions of the complainant:The complainant was not present for the virtual hearing

hence her written submissions were taken on record. She submitted in her complaint that

when she approached PNB for renewing her policy, she was informed that The New India

Assurance Co Ltd is no longer offering the policy and asked her to consider any of the other

alternative policies from The Oriental Insurance Co Ltd, Bajaj Allianz and other Insurance Cos.

She stated that the premia for these alternative policies were exorbitant and were around

2.5-3.5 times the premium she paid last year for the instant policy. She was advised by PNB

that if she is interested she could approach The New India assurance Co Ltd but they were

not contactable either on phone or designated emails. Finally, she was able to contact one

official who informed her that the policy has been withdrawn and she could opt for the

Individual Mediclaim Policy. The premium for the same was quoted as Rs.40,000/-,i.e. 4 times

the premium she was paying. Since the deadline for renewal was approaching and she was

receiving no assistance from either PNB or The New India Assurance, she had no option but

to look for an alternative policy. Subsequently, she took a Top-up Policy of Bajaj Allianz for a

premium of Rs.17,000/- for which the policy excludes the first Rs.2lacs of the claim and in that

sense could be onerous. She wished to remain in earlier New India Family Floater Group

Mediclaim Policy. The complainant added in her complaint that upon enquiry with the

management of the Insurer, The New India Assurance Co Ltd, she was informed that as per

the withdrawal of policy rules, the policyholders are provided with an option to choose from

an alternative policy for individual health product available with the Company subject to

acceptance and applicable terms & conditions of the new policy. She added that the

alternative policy plan offered was unjustified and not in consonance with the obligations of

the Insurer and they have a right to be informed in advance about the up gradation of policy

features, premium and also term & conditions at a prior date. Therefore, the complainant

requested for suitable insurance cover at an affordable level of premium and to ensure

continuity benefits from the date when renewal was due.

Contentions of the Respondent:It was contended on behalf of the Respondent that under

Bancassurance, PNB was their Corporate Agent since 26.07.2017 and account holders of the

bank were issued Mediclaim Policies under the tie-up. MrsRenuWadhwa, an account holder

of the bank wasissued New India Family Floater Mediclaim.The agreement between the

instant Bank and TheNew India Assurance Co Ltd wasterminated and the existing New India

Family Floater Mediclaim Policy was withdrawn w.e.f.22.04.2020. Hence, the bank was

instructed to stop issuing policies under their tie-up. The Insured requested the Respondent

toprovide a suitable alternative plan, vide her email dt.25.11.2020 for which they replied on

26.11.2020 statingthat thesaid agreementhad been terminated by PNBand not by The New

India Assurance Co. However,if the Insured wishes to take a policy with them, she could opt

for migrating her policy to their individual health product available for migration and subject

to acceptance and applicable terms and conditions of the new policy.The Respondent

reiterated that they made all efforts to convince the Insured to migrate to other policies as

offered, however she failed to exercise the option.

Forum’s Observations/Conclusion: The Forum noted that the agreement between the

instant Bank and The New India Assurance Co Ltd was terminated and the existing New India

Family Floater Mediclaim Policy was withdrawn w.e.f.22.04.2020 and this was communicated

to the Bank and the Bank has, in turn, issued a Public Notice about discontinuation of this

Group Mediclaim policy and also informed the policy holders that they could renew their

policies with existing general insurance partners Bajaj Allianz Insurance Co Ltd and The

Oriental Insurance Co Ltd. However, the Insurance Company/Bank has not informed the

customers individually. It is noted that the complainant has insured herself under Bajaj Allianz

Insurance Co Ltd.’s Top-up Policy, post expiry of the above Group Mediclaim Policy.

On detailed analysis of the written statement and oral submissions made by both the parties during the hearing, the Forum has come to the conclusion that Company’s stand of non-renewal of above policy is sustained.

AWARD

The complaint of Mrs RenuWadhwa against The New India Assurance Co Ltd with regard to non-renewal of above Policy does not sustain.

It is particularly informed that in case the award is not agreeable to the complainant, it would be open for him/her if he/she so decides to move any other Forum/Court as he/she may consider appropriate under the laws of the land against the Respondent Insurer.

Dated at Pune this 25th day of August,2021.

(VINAY SAH)

INSURANCE OMBUDSMAN


MUMBAI & GOA



OMBUDSMAN : SHRI VINAY SAH

COMPLAINANT - MR. SERVICE LEE TECHNOLOGIES PVT. LTD.

VS

RESPONDENT : THE NEW INDIA ASSURANCE CO. LTD.



VIRTUAL HEARING

1 Name & Address of the Complainant

Service Lee Technologies Pvt. Ltd.

Mumbai

2 Policy No:

Type of Policy


Sum Insured

14010434190400000009

New India Floater Flexi Group Mediclaim Policy

11.06.2019 – 10.06.2020

Rs.3,00,000/-

3 Name of Insured

Name of the policy holder

Mr. Reynold Louis

Service Lee Technologies Pvt. Ltd.

4 Name of Insurer The New India Assurance Co. Ltd.


6 Reason for repudiation Hospitalization for diagnostic purpose


8 Nature of complaint Total Repudiation of claim

9 Amount of claim Rs.34,481/-

10 Date of Partial Settlement ----

11 Amount of relief sought Not mentioned

12 Complaint registered under Ombudsman Rules, 2017

Under Rule 13(b)

13 Date of Hearing 27.07.2021 - 3.00 p.m. (Virtual Hearing)


a) For the complainant Mr. Amit Aphale

b) For the insurer Mr. Shishir Kumar

Dr. Bharti - Health India TPA



Brief facts of the case: Complainant’s employee Mr. Reynold Louis was admitted to Godrej Memorial Hospital from 31.01.2019 to 01.02.2019 for the treatment of Polycythemia. Complainant approached this Forum with a complaint against repudiation by the Respondent The New India Assurance Co. Ltd. of a claim lodged under the policy for the said hospitalization on the ground that expenses for diagnostic procedure are not payable as per Clause no. 4.4.11 of the policy.

Contentions of the Complainant: Mr. Amit Aphale on behalf of the Complainant appeared before the Ombudsman in the online hearing held on 27.07.2021. He stated that one of their Employees Mr. Reynald Louis suffering from polycythemia, underwent biopsy at Godrej Memorial Hospital on 31.01.2019 as per the doctor’s advice. However, Respondent repudiated the claim lodged under the policy for the same stating that the Claim was for diagnostic purpose and is not payable as per the Policy terms. Mr. Aphale submitted that the illness requires the patient to be under constant treatment with a Specialist for getting better

and also to control the Illness. Bone Marrow biopsy and the medications along with that is a necessity for the person and it requires hospitalization. All these are done in the course of the treatment and are incidental and required to the positive existence of the ailment. The ailment conforms to a blood disease called Erythrocytosis where the body produces excess of red cells which can cause ischemia as per the treatment analysis. The course of treatment could be reviewed in case there is any further development with additional medical information provided, as per what was stated by the treating doctor. He therefore pleaded for settlement of the claim.

Contentions of the Respondent: Mr. Shishir Kumar along with Dr. Bharti of TPA represented on behalf of the Respondent. Dr. Bharti submitted that the Patient Mr. Reynold Louis was hospitalized at Godrej Memorial Hospital from 31.01.2019 to 01.02.2019 for the treatment of Polycythemia with history of HB 18.7 & advice for bone marrow biopsy. Patient had h/o phlebotomy done on 13.01.2019 and 25.01.2019. Also, the Patient is a k/c/o HTN since 1 month & bronchial asthma. As per medical documents, patient was hospitalized for bone marrow biopsy for diagnostic purpose. Hene the claim was repudiated under policy clause no. 4.4.11 which reads as: “Any medical expenses incurred for or arising out of Diagnosis, X-ray or Laboratory examination not consistent with or incidental to the diagnosis of positive existence and treatment of any ailment, sickness or injury, for which confinement is required at a Hospital.” Dr. Bharti added that the said procedure is also not included in the Day Care list under the policy.

Forum’s Observations/Conclusion: After scrutiny of the documents produced on record coupled with the depositions of both the parties, the Forum observed that Mr. Reynold Louis is a k/c/o Erythrocytosis. As certified by his treating Haematologist, he is a confirmed case of Erythrocytosis - also known as polycythemia in which disease, the body produces excess red cells which can cause ischemia with a lot of morbidity and mortality. This is an established hematological disease needing treatment with regular aspirin, intermittent phlebotomies, avoidance of iron containing medicines and occasionally Hydroxyurea&Pegylated Interferon. He had already undergone phlebotomy on 13.01.2019 and 25.01.2019. On 31.01.2019, he was again hospitalized with HB 18.7. During hospitalization, he underwent bone marrow aspiration and biopsy under all aseptic precautions done by Dr. AmolAkhade. Respondent repudiated the claim for the same on the ground that it was a diagnostic procedure not payable under the policy. The Forum does not find fault with the contention of the Respondent that in the ordinary course, Biopsy is considered as a diagnostic procedure. However, in the instant case, the patient was already a diagnosed case of Polycythemia and by virtue of the nature of disease suffered by him, he was required to undergo regular checks and evaluation to assess the progression of the disease based on which further line of treatment could be decided and administered if and as required from time to time. It also requires hospitalization and has to be done under all aseptic precautions.

In the light of the above, strictly speaking it would not be correct to say that the hospitalization of Reynold Louis was solely for diagnostic purpose as it was necessary to assess the progression of his disease which was already diagnosed and was of a serious nature, to decide the further course of treatment to be adopted based on the prognosis. Also, with advancement in medical technology, such procedures do not require 24 hours’ stay in the hospital. In view of the foregoing, taking a considerate view of the situation, the Forum is

therefore, of the view that the subject claim be allowed. The decision of the Respondent is thus set aside by the following Order.

AWARD

Under the facts and circumstances of the case, The New India Assurance Co. Ltd. is directed to settle the claim for the admissible amount of Rs.33,960/- incurred for the hospitalization of Mr. Reynold Louis on 31.01.2019, towards full and final settlement of the complaint. As per the regulation of IRDAI, penal interest @ 2% above Bank Rate shall be applicable for delayed compliance of award after 30 days from the issuance of the order.

The attention of the Complainant and the Insurer is hereby invited to the following provisions of the Insurance Ombudsman Rules, 2017:

a) As per Rule 17(6) of Insurance Ombudsman Rules, 2017, the insurer shall comply with the award within thirty days of the receipt of the award and intimate compliance of the same to the Ombudsman.

b) As per Rule 17(8) the award of Insurance Ombudsman shall be binding on the Insurers.

Dated at Pune this 3rd day of August, 2021.

VINAY SAH

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATE OF WESTERN UP AND UTTARAKHAND (UNDER INMSURANCE OMBUDSMAN RULE 2017

OMBUDSMAN – SH. C.S. PRASAD CASE OF MR. MADHUL SINGHAL V/S BHARTI AXA INS. COMPANY LTD.

COMPLAINT REF. NO. : NOI- H – 007 – 2122 - 0083 AWARD NO:

1. Name & Address of the Complainant Mr. (Dr.) Madhul Singhal

25/2, New Kumaon Vihar,

Ranikhet Cantt,

District Almora, Uttarakhand-263645.

Ph. No. 0 7011801637

2. Policy No:

Type of Policy

Policy period

JA 651007

Group Health Assure Policy

13.05.2020 to 12.05.2021



Mr. Madhul Singhal

Mr. Madhul Singhal

4. Name of the insurer Bharti Axa Insurance Company Ltd.

5. Date of Repudiation 11.09.2020 and 14.01.2021

6. Reason for repudiation --


8. Nature of complaint Group Mediclaim

9. Amount of Claim NA


11. Amount of relief sought Rs.62,500/- for three claims as per Annex

VI A


IOB rules, 2017

13 (1) b

13. Date of hearing/place 06.08.2021 / Noida


a) For the Complainant Mr. (Dr.) Madhul Singhal

b) For the insurer Sh. Rishikant, Senior Executive-Legal Cell



17) Brief Facts of the Case :- Mr. (Dr.) Madhul Singhal, the Complainant had taken Group

Health Assure Policy No. JA 651007 from Bharti Axa General Ins. Company for the period from 13.05.2020 to 12.05.2021. The Insurance Company repudiated his two Covid related claims at the time of lodging the complaint. Later, one more claim was repudiated by the Insurer. Aggrieved, he requested the insurer including its GRO to reconsider the claims but failed to get any relief. Thereafter, he has preferred a complaint to this office for resolution of his grievance.

18) Cause of Complaint : -

a) Complainant’s Argument :- The Complainant Mr. Madhul Singhal stated in his complaint that after the onset of Covid-19 pandemic, one plan was launched by Bharti Axa gen. Ins. Company for Airtel customers and the same was being sold on Airtel Thanks App. The plan was launched in April 2020. The Complainant checked the same on his Airtel App and read the FAQs and purchased the policy on 12th May, 2020. After purchase, no copy of policy was received by him on email/hard copy. Only notification of policy issued was generated on App. Finally, Policy copy was received only on 18th January, 2021.

Three claims were preferred in the duration of policy as per following details: i) Claim No. Q 0344794 (for quarantine claim; 50% Sum Assured of Rs.12,500/-). The

Claim was intimated on 18th June 2020. Claim was preferred because the complainant was quarantined in a military facility for 14 days from 28.05.2020 to 11.06.2020. Quarantine Certificate was submitted along with all certificates and documents. The Test was not carried out during quarantine period as he did not develop any symptoms of Covid -19 as evaluated by Medical Officer. Also as per MOHFW guidelines, no testing were recommended for asymptomatic persons.

ii) Claim No. Q 0364219 (for diagnosis cover claim; 100% sum assured of Rs.25,000/-).

The claim was intimated on 06.11.2020. The claim was preferred because the complainant was tested positive for Covid-19. He was tested positive by VRDL Laboratory of Govt. Medical College, Haldwani, Uttarakhand on 05.11.2020 which is an ICMR approved laboratory. Test Report was submitted along with all certificated and documents.

iii) Claim No. Q 0383798 (for diagnosis cover claim; 100% sum assured of Rs.25,000/-).

The claim was intimated on 13.05.2021. The claim was preferred because the complainant was tested positive for Covid-19. He was tested positive by VRDL Laboratory of Govt. Medical College, Haldwani, Uttarakhand on 30.04.2021 which is an ICMR approved laboratory. Test Report was submitted along with all certificated and documents.

His three claims for total amount of Rs.62,500/- were repudiated by the Insurance Company on false basis.

b) Insurers’ argument:- The Insurer stated in their SCN that the complainant had obtained a Group Health Insurance Policy from Bharti AXA General Insurance for the period 13-05-2020 to 12-05-2021.

As per the documents submitted, the Insured got admitted for quarantine at Military Hospital, Ranikhet on 28-05-2020 and was discharged from there on 11-06-2020.

However, the verification and scrutiny of the claim documents reveals that the insured did not actually got tested for Covid 19, which is a requirement as per the policy terms and conditions which states as under:

Exclusion Clause Number 3: Special Conditions applicable

50% of the Sum Insured shall be payable if the patient has been quarantined in a Government/Military Facility for atleast 14 days due to concern about a possible exposure to Covid -19, but this is ruled out after evaluation.

The policy certificate issued to the insured specifically mentioned that the claim shall be payable only when a possible exposure to Covid 19 has been ruled out after evaluation under ICD Z03.818, i.e. a Covid Test has to be done, therefore the Insured is not entitled to claim 50% of the Sum Insured amount as no Covid Test was done on part of the Insured in order to get quarantined at the Military Centre, suspecting an exposure to Covid 19.

It is also pertinent to mention that even in the quarantine certificate it is mentioned that no Covid test was performed on the Complainant as per Quarantine Certificate.

Also, in respect of the other claims lodged by the Complainant, it is submitted that the Insured tested positive for Covid on 05-11-2020.

However, the claim was not paid to him as he was home quarantined thus not incurring any In-Patient Care Expense and as per the requirements of the policy.

Restricted Ailments coverage (Upon request from the proposer and specifically agreed by the Company, the scope of coverages, Sum Insured under In-Patient Care Expenses of the policy shall become restricted to the named ailments as specified in the Policy Schedule/Certificate of Insurance)

In light of the above, the claim of the Complainant was repudiated vide repudiation letter dated 11-09-2020.

That in light of given facts & circumstances, prevailing policy conditions & laws, guidelines issued by various statutory authorities scrutinizing the working of Insurance Companies the present complaint deserves a dismissal on the below mentioned grounds:

i) That the complainant did not get the Covid test done from ICMR registered lab which

is mandatory, hence the claim was repudiated; ii) That the Claim of the Complainant is not covered under the Policy Terms and

Conditions and hence is not payable; iii) The Insured did not incur any expense under In-Patient Care Expenses, hence, the

claim of the Insured does not fall under the purview of the Policy Terms & Conditions specially & specifically mentioned in the Policy certificate.

19) Reason for Registration of Complaint: - Repudiation of three Mediclaims

20) The following documents were placed for perusal. a) Complaint letter b) SCN c) Policy Copy d) Annexure VI A

21) Observations and Conclusion :-

Both the parties appeared for personal hearing through video call and reiterated their submissions. The Complainant Mr. Madhul Singhal reiterated that he purchased a policy which was launched by the Insurer on Airtel Thanks App on 12th May, 2020. He has alleged that his three claims for total amount of Rs.62,500/- were repudiated by the Insurance Company on false basis. The Insurance Company clarified that first of all, the sum insured of the Policy is Rs.25,000/- which is maximum liability of the Insurer. The Company further stated that the Insured got admitted for quarantine at Military Hospital, Ranikhet on 28-05-2020 and was discharged from there on 11-06-2020. However, as per documents submitted by the insured, it is found that the complainant did not actually got tested for Covid 19, which is a requirement as per the policy terms and conditions which states as under:

Exclusion Clause Number 3: Special Conditions applicable

50% of the Sum Insured shall be payable if the patient has been quarantined in a Government/Military Facility for atleast 14 days due to concern about a possible exposure to Covid -19, but this is ruled out after evaluation.

The policy certificate issued to the insured specifically mentioned that the claim shall be payable only when a possible exposure to Covid 19 has been ruled out after evaluation under ICD Z03.818, i.e. a Covid Test has to be done. But no Covid Test was done as is evident by the quarantine certificate which mentions that no Covid test was performed on the Complainant.

Ongoing through the documents exhibited and the oral submissions made by both the parties, it is observed from the quarantine certificate in the first claim, that no Covid test was performed on the Complainant which is mandatory for claim as per Special Conditions applicable’s Exclusion Clause Number 3. Hence, the claim was rightly repudiated by the Company.

The complainant was tested positive for Covid-19 on 05.11.2020 and lodged the second claim which is also not payable as he was home quarantined thus not incurring any In-Patient Care Expense which is clearly mentioned on the face of the policy under “Restricted Ailments coverage : Upon request from the proposer and specifically agreed by the Company, the scope of coverages, Sum Insured under In-Patient Care Expenses of the policy shall become restricted to the named ailments as specified in the Policy Schedule/Certificate of Insurance”.

The complainant was again tested positive for Covid-19 on 30.04.2021 and lodged the third claim which was similar to second claim and also not payable as he was again home quarantined thus not incurring any In-Patient Care Expense which is clearly mentioned on the face of the policy under “Restricted Ailments coverage : Upon request from the proposer and specifically agreed by the Company, the scope of coverages, Sum Insured under In-Patient Care Expenses of the policy shall become restricted to the named

ailments as specified in the Policy Schedule/Certificate of Insurance”. Hence, I see no reason to interfere with the decision of the Insurance Company.

AWARD

Taking into account the facts and circumstances of the case and the submissions made by both the parties during the course of hearing, I see no reason to interfere with the decision of the Insurance Company.

The complaint is treated as disposed off accordingly.

Place: Noida. C.S. PRASAD Dated: 12.08.2021 INSURANCE OMBUDSMAN (WESTERN U.P. & UTTARAKHAND)

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF WESTERN U.P. & UTTARAKHAND

UNDER INSURANCE OMBUDSMAN RULES, 2017 OMBUDSMAN – SH. C.S. PRASAD

CASE OF MR. KAPIL AGRAWAL V/S. UNITED INDIA INSURANCE COMPANY LTD. COMPLAIN REF. NO.: NOI-H-051-2122-0085

AWARD NO:

1. Name & Address of the Complainant Mr.Kapil Agrawal

S/O Sh. Kanti Sharan,

Gopal Bhawan, Mathmaliyan,

Pilkhuwa, Uttar Pradesh-245304.

Ph. No.09837635574

2. Policy No:

Type of Policy


Sum Insured

2220032819P108391166

Synd Arogya (Group Health Insurance)

04.01.2020 to 03.01.2021

Rs.2,00,000/-

3. Name of the Patient

Name of the Insured

Mr.Kapil Agrawal

Mr.Kapil Agrawal

4. Name of the insurer United India Insurance Company Limited


6. Reason for repudiation Required documents not submitted by

the Insured



9. Amount of Claim --

10. Date of Partial Settlement --

11. Amount of relief sought Rs.1,68,629/- claim amount and Rs.5 Lacs

Compensation as per Annex VI A


IOB rules, 2017

13 (1)(b)

13. Date of hearing/place 06.08.2021 / NOIDA


a) For the Complainant Mr.Kapil Agrawal

b) For the insurer Mr. Om Parkash Meena ,

Sr. Branch Manager



17. Brief Facts of the Case:- Mr.Kapil Agrawal, the Complainant had taken Group Health

Insurance Policy No.2220032819P108391166 for the period from 04.01.2020 to

03.01.2021 for S.I. Rs.2,00,000/-. The reimbursement of hospitalization bills were not settled by the Insurance Company. Aggrieved, he requested the Insurer including its GRO to reconsider the claim but failed to get any relief. Thereafter, he has preferred a complaint to this office for resolution of his grievance.

18. Cause of Complaint:-

a) Complainant’s argument:- Mr.Kapil Agrawal, the Complainant stated in his complaint that his Claim No.CCN700726 for Rs.1,66,701/- was not settled by the Insurance Company for the last nine months. However, he has submitted all the documents to the Insurer.

b) Insurers’ argument:- The Insurer in their SCN stated that Mr. Kapil Aggarwal was

admitted to Le Crest Hospital, Vasundhra, Ghaziabad on 11/09/2020 due to fever. Later, reimbursement claim was filed with TPA M/s East West Assist Pvt. Ltd. Since, he was diagnosed with Corona so the TPA asked for Corona Positive Report of the patient.

Insured lodged grievance with them regarding pendency of his claim and after asking from TPA, the Company conveyed that Corona positive report is required by the TPA to process the claim. They also sent 3 reminder letters to the Insured dated 18/02/2021, 16/03/2021 and 11/05/2021 but they didn't receive the document as on date. Now, they have come to know that Insured lodged complaint with Ombudsman. The Corona positive Report of the patient is still pending, as required by the TPA.

19) Reason for Registration of Complaint: - Rejection of Mediclaim 20) The following documents were placed for perusal.

a) Complaint copy b) Policy Copy c) SCN d) Annexure VI A

21. Observations and Conclusion :-

Both the parties appeared for personal hearing through video call and reiterated their submissions. The Insurance Company reiterated that the claim was closed due to the non submission of Covid-19 Report. But, during the discussion, the Insurance Company stated that being a customer centric entity, as a pro-customer measure, they are ready to settle the case and offered to pay the claim to the Complainant on the basis of Chest X-ray and HRCT Chest. Hence, it is directed to the Insurer to pay the above admissible claim amount to the Complainant as agreed by them.

AWARD

Taking into account the facts and circumstances of the case and the submissions made by both the parties during the course of hearing, it is directed to the Insurer to pay the admissible claim amount to the Complainant as agreed by them.


22. The attention of the Complainant and the Insurer is hereby invited to the following

provisions of Insurance Ombudsman Rules, 2017:

a) According to Rule 17(6) of Insurance Ombudsman Rules,2017, the insurer shall comply with the award within thirty days of the receipt of the award and intimate compliance of the same to the Ombudsman.


PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF WESTERN U.P. & UTTARAKHAND

UNDER INSURANCE OMBUDSMAN RULES, 2017 OMBUDSMAN – SH. C. S. PRASAD

CASE OF MS. SONIA GOYAL VS. CHOLA MS GENERAL INS. CO.LTD. COMPLAINT NO: NOI-H-012-2122-0106

AWARD NO:

1. Name & Address of the Complainant Ms. Sonia Goyal

A-2, Sector-53, Noida,

Uttar Pradesh-201301

Ph. No. 9891337512

2. Policy No:

Type of Policy


Sum Insured

2876/00047291/000004/000/00

Group Health Insurance (Family Floater)

04.02.2020 to 03.02.2021

Rs.5,00,000/-



Kashish Goyal, Daughter

Ms. Sonia Goyal

4. Name of the insurer Chola MS General Insurance Co. Ltd..


6. Reason for repudiation Repudiation of claim due to non

submission of required documents



9. Amount of Claim N.A.

10. Date of Partial Settlement ---

11. Amount of relief sought Rs.97,000/- as per Annex VI A


Rule no: of RPG rules

13 (1) (b)

13. Date of hearing/place 06.08.2021 / Noida


a) For the Complainant Ms. Sonia Goyal

b) For the insurer Abhishek Nigam, Assistant Manager Legal



17. Brief Facts of the Case:- Ms. Sonia Goyal, the Complainant had taken Group Health

Insurance (Family Floater) No. 2876/00047291/000004/000/00 for the period from 04.02.2020 to 03.02.2021 for the Sum Insured of Rs.5,00,000/-. The claim for reimbursement was repudiated by the Insurance Company. Aggrieved, she requested the Insurer including its GRO to reconsider the claim but failed to get any relief. Thereafter, she has preferred a complaint to this office for resolution of her grievance.

18. Cause of Complaint:-

a) Complainant’s argument:- Ms. Sonia Goyal, the Complainant stated that the claim no.

2876032262 for reimbursement of claim amount of Rs. 97,000/- was closed by the Insurer.

Her daughter Kashish Goyal got admitted on 7th November 2020 and got discharged on 11th November 2020 in Kailash Hospital And Research Center Ltd. They have submitted all the related documents in original and photocopies also to the company. They have also submitted the letter from the treating doctor mentioning the onset and duration of illness which the Company has asked for further processing of the claim. But the Company did not settle her claim of Rs.97,000/-.

b) Insurers’ argument:- The Insurance Company stated in their SCN that

1. That without admitting the factum of the complaint, it is stated that they have issued the Group Health Insurance Policy (Family Floater) vide policy number 2876/00047291/000/00 issued in the name of complainant Ms. Sonia Goyal for the period 04/02/2020 to 03/02/2021 for sum assured of Rs. 5,00,000/- covering complainant, spouse and two children.

2. That the Complainant's child was admitted at Kailash Hospital, Noida on 09/07/2020 as was diagnosed for Acute Lower PIVD & Osteiporosis. She got admitted on 07/11/20 and was discharged on 11/11/20.

3. Insured claimed for Rs.97,000/- for the expenses for treatment incurred during hospitalization, Pharmacy bill, pre hospitalization bills and post hospitalization bills.

4. That the claim was submitted by the complainant with the Insurance Company and

while scrutinizing the documents it was observed that some vital claim and treatment related documents are not submitted which and very necessary for processing the claim. Subsequently a query letter dated 24.02.21 was send to the complainant requesting to submit the required documents within 15 days. Below are the documents as required -

● Patient first complained and sought medical attention with regards to previous episode of tetanic spells along with consultation papers.

● Furnish details of onset, progress and duration of the ailment and treatment taken by

the patient till date.

● Letter from treating doctor mentioning the onset, etiology and duration of illness.

● First and previous consultation papers pertaining to present illness.

5. That two reminder letters dated 11/03/21 & 26/03/21 were also send to the complainant but as no reply was received, due to non submission of documents as required, a repudiation letter dated 27/04/21 was send to the complainant.

6. That adequate time and reminders were also sent to the complainant to provide the required documents which are necessary for processing the claim. But, since no documents were provided, the Insurance Company was constrained to repudiate the claim on the ground of Non – Submission of documents.

19) Reason for Registration of Complaint: - Repudiation of Mediclaim 20) The following documents were placed for perusal.

a) Customer complaint b) Annexure vi and vi (a) c) Policy Copy d) SCN

21 Observations and Conclusion :- Both the parties appeared for personal hearing through video call and reiterated their submissions. The Complainant Ms. Sonia Goyal reiterated that the claim for reimbursement of claim amount of Rs. 97,000/- was closed by the Insurer. Although, they have submitted all the related documents in original and photocopies also to the company, but the Company did not settle her claim of Rs.97,000/-. The Insurance Company reiterated that the claim was submitted by the complainant with the Insurance Company and while scrutinizing the documents, it was observed that some vital claim and treatment related documents are not submitted which are very necessary for processing the claim.

Below are the documents as required - ▪ Patient first complained and sought medical attention with regards to previous

episode of tetanic spells along with consultation papers. ▪ Furnish details of onset, progress and duration of the ailment and treatment taken

by the patient till date. ▪ Letter from treating doctor mentioning the onset, etiology and duration of illness. ● First and previous consultation papers pertaining to present illness.

Since, no documents were provided; the Insurance Company repudiated the claim on the ground of Non – Submission of documents. During the course of hearing, the complainant was advised to submit the above mentioned documents to the Insurer within 14 days from the hearing date for settlement of her claim. Ongoing through the documents exhibited and the oral submissions made by both the parties, it is observed that the complainant had not submitted the required documents to the Insurer. The complainant is directed to submit the above mentioned required documents to the Insurer within 14 days from the hearing date and the Insurance

Company is directed to pay the admissible claim amount to the complainant within 15 after receiving the above mentioned documents under intimation to this office.

AWARD

Taking into account the facts and circumstances of the case and the submissions made by both the parties during the course of hearing, The complainant was directed to submit the above mentioned required documents to the Insurer within 14 days from the hearing date and the Insurance Company is directed to pay the admissible claim amount to the complainant within 15 after receiving the above mentioned documents.


22. The attention of the Complainant and the Insurer is hereby invited to the following provisions of Insurance Ombudsman Rules, 2017:

a) According to Rule 17(6) of Insurance Ombudsman Rules, 2017, the insurer shall comply with the award within thirty days of the receipt of the award and intimate compliance of the same to the Ombudsman.


PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATE OF WESTERN U.P. AND UTTARAKHAND UNDER INSURANCE OMBUDSMAN RULES 2017

OMBUDSMAN – SHRI C.S. PRASAD CASE OF MR. RAKESH KUMAR GOEL V/S SBI GENERAL INSURANCE CO. LTD.

COMPLAINT REF: NO: NOI-H-040-2122-0063 AWARD NO:

1. Name & Address of the Complainant Mr. Rakesh Kumar Goel B15, Vasu Greens Colony, Rishi Nagar, Baghpat Road, Meerut-UP-250002.

2. Policy No: Type of Policy Duration of policy/Policy period

0000000005886696 Group Health Insurance Policy 20.02.2021 to 19.02.2022

3. Name of the insured Name of the policyholder

Mr. Rakesh Kumar Goel Mr. Rakesh Kumar Goel

4. Name of the insurer SBI General Insurance Co. Ltd.

5. Date of Repudiation n.a.

6. Reason for repudiation n.a.


8. Nature of complaint Partial payment of claim - Group Mediclaim

9. Amount of Claim Rs.64,822/-

10. Amount of Partial Settlement Rs.33,385/-

11. Amount of relief sought Rs.31,437/-

12. Complaint registered under IOB rules

13 (1) (b)

13. Date of hearing/place 09.08.2021 at Noida - Online Hearing


a. For the Complainant Mr. Pulkit Goel, Son

b. For the insurer Ms. Chynicka Modie, Sr. Executive-Legal



17) Brief Facts of the Case: This complaint is filed by Mr. Rakesh Kumar Goel against SBI General Insurance Co. Ltd. for partial payment of his hospitalization claim.


Complainant’s argument: The complainant was covered under Group Mediclaim Policy from SBI, bearing Policy No. 0000000005886696. He was admitted in Dhanvantri Jeevan Rekha Hospital, Meerut, from 16.3.2020 to 18.3.2020 for treatment of Prostatomegaly Median Lobe. The insurance company deducted Rs. 31437/- from the claim amount.

Insurers’ argument: The Insurance Company in their SCN dated 22.06.2021 wherein they stated that the aforesaid claim had already been settled by them for Rs. 33,385/- against the total claimed amount of Rs. 64,822/- in conformity with the terms and conditions of the Policy. The complainant was hospitalized in “Dhanvantri Jeevan Rekha Ltd.” from 16/03/2020 to 18/03/2020 for the treatment of prostatomegaly, median lobe for which he underwent plasma kinetic resection of the prostate. The break-up of the inadmissible amount was Rs.3600/- excess room and nursing charges, Rs.155/- betadine, Rs. 216/- sterillium, Rs. 240/- gloves, Rs. 65/- camera cover, not payable and Incremental deduction of Rs. 27,161/- . The Incremental deduction related to the excess room and nursing charges, expenses on Consumables and an Incremental deduction of Rs 27,161/-, over and above the sum insured opted. The sum insured was Rs. 1,00,000/- and the eligible room rent was Rs.1000/- per day, hence, the excess charges related to Surgeon, Operation Theatre, Doctor Visit and Investigation, over the policy capping, amounting to Rs 27,161/- were deducted under the head of incremental deductions.

19) Reason for Registration of Complaint: - Partial payment of Claim 20) The following documents were placed for perusal.

a) Complaint letter b) Policy document c) Payment Voucher d) SCN

21) Observations and Conclusion: - The complainant’s son and the representative of the insurance company were present for an online hearing on 09.08.2021. The complainant’s son stated that due to Covid situation, his father was admitted in hospital in higher category of room due to non-availability of his entitled rooms. He has no objection with the deduction of difference in room rent but has contested the deduction of other charges. The insurance company reiterated that the claim was settled as per the terms and conditions of the policy. During the course of hearing, it is noted that it is unclear whether the higher category room was a choice of the complainant or was enforced upon him by the hospital authorities. The complainant was asked to submit a documentary proof from the hospital to prove that there was no room available as per the patient’s entitled category. The complainant vide his email dated 11.08.2021 expressed his inability to produce any documentary proof from the hospital but insisted to settle the claim for the reason that incremental or proportionate deduction was not conveyed to him at the time of settling the policy. On the other hand, the insurance company confirmed via their email dated 10.08.2021 that Dhanvantari Hospital was a network hospital but instead of opting cashless hospitalization, the complainant opted for a higher category room and submitted a reimbursement claim.

On going through the documents exhibited and the oral submissions made by both the parties during the hearing, it is noted that the insurance company settled and paid the claim as per the terms, conditions and exclusions of the policy. The complainant’s son himself admitted that due to Covid-19 scenario they opted to choose a higher rated room. The policy in ‘Scope of Cover’ clearly states that “Insurer shall pay the expenses reasonably and necessarily incurred by or on behalf of the Insured Person under the following categories but not exceeding the Sum Insured and subject to deduction of any deductible as reflected in the policy schedule in respect of such Insured person as specified in the Schedule: 1. Room,

Board & Nursing Charges as provided by the hospital: up to 1% of the Sum Insured for Normal Room per day. In case the insured opts for a higher room category than his eligibility the same can be covered upon specific acceptance by the insurer or Administrator. In such a case all incremental Expenses pertaining to room rent, medical practitioners / specialists fees and other incidental Expenses to be borne by the insured.” The insurance company has settled the claim rightly and I see no reason to interfere with the decision of the insurance company.

The complaint is closed.

AWARD

Taking into account the facts and circumstances of the case and the submissions

made by both the parties, the insurance company has settled the claim rightly and I

see no reason to interfere with the decision of the insurance company.

The complaint is closed.


PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, PUNE (STATE OF MAHARASHTRA EXCEPT MUMBAI METRO)

UNDER SECTION 16/17 OF THE INSURANCE OMBUDSMAN RULES-2017 OMBUDSMAN– VINAY SAH

CASE OF Mrs Chandraprabha P Patil V/S Star Health &Allied Ins Co Ltd COMPLAINT NO: PUN-H-044-1920-0429

Award No IO/PUN/A/HI/ /2021-22


Mrs Chandraprabha P Patil Navi Mumbai

2. Policy No: Type of Policy:

P/171126/01/2019/001431 Group Mediclaim Policy

3. Policy period: 12.09.2018 to 11.09.2019

4. Sum Insured Rs.5,00,000/-

5. Date of inception of first policy: 11.09.2017

6. Name of the Insured Member: Name of the Policyholder:

Mrs Chandraprabha P Patil; 53 years Sangli Vaibhav Co-op Cr. Soc. Ltd.

7. Name of the Insurer Star Health & Allied Ins. Co. Ltd.

8. Reason for repudiation/Partial Settlement: Repudiation as per Excl. Cl. No 19

9. Date of receipt of the complaint 09.10.2019

10. Nature of complaint: Immunotherapy charges not payable

11. Amount of Claim: Rs.8,00,000/-

12. Insurance Ombudsman Rule (IOR)2017 under which the Complaint was registered:

Rule 13 1 (b)

13. Date of hearing/Place: 25.05.2021; Online


a) For the Complainant: Mrs. Chandraprabha Patil

b) For the insurer: Dr. Smita Sonawane

15. Complaint how disposed: Closed after payment of claim by RI


Complainant was diagnosed with Ca Left Breast in June 2008 and was under treatment of chemotherapy. She was diagnosed with recurrent Ca Breast and admitted on 23.11.2018 in Daycare Angels Hospital (Shushrut Hospital & Research Centre), Mumbai, for undergoing 15th cycle of chemo. Complainant approached this Forum with a complaint against denial by the Respondent, Star Health & Allied Insurance Co Ltd of the claim lodged under the policy in respect of the said hospitalization.

Contentions of the Complainant:

The complainant appeared and deposed before the Forum in the joint hearing with the Company. She submitted that she is covered under the Group Mediclaim policy where the Master policyholder is Sangli Vaibhav Co-op Cr Society since September 2017. She stated that she lodged a reimbursement claim of Rs.2,91,150/- which was repudiated by RI stating the reason that the medicines used were for immunotherapy and were not payable as per Exclusion Clause No.19. She approached RI for reconsideration of claim but the decision was upheld by them. She, also, contended that the claim lodged in the last year was paid upto her sum insured of Rs.3 lacs only and the further claim she has claimed from the buffer amount granted in the last year’s policy. But the same is yet not settled from the buffer amount. The letter required from the policyholder for buffer amount to be settled was also furnished by the complaint. Hence she approached this Forum for redressal of her grievance.

Forum’s Observations/Conclusion :

Here, two issues are involved:

➢ Whether the RI has applied the policy exclusion clause no.19, correctly and

➢ RI’s liability in case of buffer amount granted under the policy year 2017-18.

During the hearing, the RI was asked to consider the claims as the application of exclusion clause of immunotherapy without indication is not established. Forum finds it is with indication of treatment of cancer and falls under a type of advanced chemo therapy. Hence, those are admissible under the policy terms and conditions.

Complainant has not produced claim papers in respect of the claims which she is asking from buffer amount.

RI vide their mail dt 16/08/2021, have confirmed that,

1. They have made payment to the insured as per the same explaining all the deductions prior to obtaining consent.

Payment details are as mentioned below.

Payee Name Amount

Rs.

Payment Type

Cheque Date

MR.PANDURANG RAOJI PATIL 327950/- NEFT 6/8/2021

2. In policy no. P/171126/01/2019/001431, the available corporate buffer is Rs. 0/- (zero). The insured was hospitalized and reported the claim in the policy no. P/171126/01/2019/001431. It is submitted that the documents provided by the insured is pertaining to policy no. P/171126/01/2018/000891, in which the available corporate buffer is Rs.10,00,000/- which has expired at the time of claim. Hence, cannot utilized.

The complainant has not raised any grievance on the amount of payment received, so she cannot have any objection on this now.

In view of this, there is nothing left to give any monetary award in this complaint. Hence it is treated as closed.

AWARD In view of the payment of claims by RI mentioned in the complaint and no amount payable from the buffer amount of earlier policy and no further objection from the complainant on the amount of payment, complaint is treated as closed.

Dated: This 20th day of August 2021 at Pune.

VINAY SAH INSURANCE OMBUDSMAN, PUNE



CASE OF MR.GOPAL BIHANI V/S STAR HEALTH & ALLIED INS CO LTD COMPLAINT NO: PUN-H-044-2122-0073



Mr.Gopal Bihani PUNE


P/900000/01/2020/000073 (Master Policy) P/151111//01/2021/012304 (certificate policy) Star group health insurance policy-Gold for Bank of Baroda customers

3. Policy period: 31.08.2020 to 30.08.2021

4. Sum Insured 300000


6. Name & Age of the Insured: Name of the Policyholder:

Mr. Gopal Bihani,38 yrs Mrs. Neeta Gopal Bihani

7. Name of the Insurer: Star health & allied Ins co ltd

8. Reason for repudiation/Partial Settlement:

Hospitalization not required

9. Date of receipt of the Complaint: 15.04.2021

10. Nature of complaint: Settlement of claim amount

11. Amount of Claim: Rs.21500/-


Rule 13 1 (b)

13. Date of hearing/Place: 14.07.2021(ONLINE HEARING)


e) For the Complainant: Himself

f) For the insurer: Dr Anjali Rathod

15. Complaint how disposed: Allowed

Contentions of the Complainant:-

• The complainant was covered under group health policy of RI along with spouse and family. On 9.10.2020, he was declared covid +ve. On the same day he intimated to company. Since he has elderly mother and 2 children at home, he admitted himself in authorized isolation centre and then was discharged on 14.10.2020 with a condition to be in isolation at home for 12 days. The total expenditure on hospitalization was Rs.28135/-

• RI repudiated the claim stating insured patient’s vitals were stable. Hospitalization is not warranted. Upon escalation of the matter to their higher authorities, the company remitted Rs. 6665/- against the claim of Rs. 28,135/-

• He is requesting forum to intervene for full settlement of claim amount.

Contentions of the Respondent Insurer (RI):-

As per Repudiation letter dated 22.01.2021, while processing the claim records relating to the insured patient seeking reimbursement of hospitalization expenses for treatment of Covid 19, it was observed from the submitted records that the hospitalization of the insured patient was not warranted as per exclusion clause no 36- Any hospitalization not medically required. Therefore RI was unable to settle the claim under the policy and thereby repudiated the claim.

Later, the insured submitted a request for reconsideration of repudiation of claim. As per the submitted records, the vitals of patient were stable throughout the hospitalisation. Hence, the hospitalisation was not warranted and could have been treated by home isolation as per AIIMS guidelines for corona treatment. Hence they settled the claim at Rs. 1333/- per day

(total Rs. 6665/-) as home isolation package. They are stating that their package rate is the best rate compared to the top hospitals.

The decision had been taken as per the terms and conditions of the policy and based on the details/documents submitted.

Result of personal hearing with both the parties (Observations & Conclusions):

During the personal hearing on 14.07.2021 (through video-conferencing), both the parties reiterated their respective stand.

During the hearing complainant averred that he had throat infection and cough. Seeing his CT score 7/25, the doctor advised him that it is better to be under observation. Besides, he has two children and aged parents at home whose life he did not want to put in danger. Hence, he got admitted in authorized covid center for treatment and isolation. Complainant has produced PMC’s certificate for this center to work on no profit no loss basis. He contended that he is not asking for any exorbitant amount of claim. He wants reimbursement of only that much what was his expense. i.e. Rs. 21,470/-. (Balance outstanding amount)

RI submitted that they have already paid the best deal of package rate for ‘Home isolation’. They reiterated that hospitalisation was not required.

Forum observes that, during the pandemic, the new centers were opened for keeping covid+ve patients in isolation. It was need of the hour and in the same manner, the insured was advised to get himself admitted in Govt. authorized center isolation center.

In view of this, RI cannot avoid its liability from paying the charges admissible under the policy. Complaint allowed. Award follows,

AWARD Under the facts and circumstances, the RI is directed to pay Rs.21470/-less deduction as per policy terms and conditions, to the complainant, towards full and final settlement of the complaint. The award is to be settled within one month from the date of receipt of this award failing which it will attract interest at the prevailing bank rate plus 2% extra from the date of rejection of the claim till the date of payment of this award.

The attention of the Complainant and the Insurer is hereby invited to the following provisions of Insurance Ombudsman Rules 2017: 17(6) the insurer shall comply with the award within thirty days of the receipt of the award and intimate compliance of the same to the Ombudsman. 17(8) the award of Insurance Ombudsman shall be binding on the insurers. Dated: at Pune, on 18th Aug 2021

VINAY SAH INSURANCE OMBUDSMAN, PUNE


UNDER SECTION 16/17 OF THE INSURANCE OMBUDSMAN RULES-2017 OMBUDSMAN – VINAY SAH

CASE OF Mr. Harshad Oswal V/S. Star Health& Allied Insurance Co. Ltd. COMPLAINT NO: PUN-H-044-1920-0403



Mr. Harshad Ramesh Oswal 6, Shivaji Cloth Market, Budhwar Peth, Karad, Satara – 415110 (M.S.)


P/900000/01/2018/000012 Group Health Insurance(JIO)

3. Policy period: 31/03/2018 to 30/03/2019

4. Sum Insured/IDV Rs.5 lakhs

5. Date of inception of first policy: 31/03/2017

6. Name & age of the Insured: Name of the Policyholder:

Mr. Ramesh Oswal – Age: 59 years M/s Jain International Organization (JIO)

7. Name of the Insurer: Star Health & Allied Insurance Co. Ltd.

8. Reason for rejection /Partial Settlement:

Claim paid as per policy conditions

9. Date of receipt of the Complaint: 19/07/2019

10. Nature of complaint: Partial repudiation of claim

11. Amount of Claim: Rs.1,35,000/-

12. Rule of IOR 2017 under which the Complaint was registered:

13(1)(b)

13. Date of hearing/Place: 28/04/2021,(Online). Pune


a) For the Complainant: Himself

b) For the insurer: Dr. Anjali Rathod

15. Complaint how disposed: Allowed.


Complainant and his family were insured with the Respondent Insurer (RI) under the above policy for the period 31/03/2018 to 30/03/2019. The insured patient aged 59 years was hospitalized at VADT Nursing Home, Mumbai from 29/03/2019 to 30/03/2019 and was diagnosed with OTOSCLEROSIS. The Insured patient was operated for Right Ear Stapedectomy and an amount of Rs. 136051/- has been incurred towards hospitalization and Pre-hospitalization expenses. All claim related documents were submitted to the Respondent Insurer for reimbursement. Respondent Insurer settled the claim for Rs.35,000 /- out of a total reimbursement claim of Rs.1,36,051/-. The total deduction in the claim is amounting to Rs.1,01,051/-. The complainant then approached the Grievance Cell of the RI with the request to review and re-consider the payment of his balance amount of claim but they have not acceded to his request. Aggrieved with this decision, the complainant has approached the forum for resolution of his grievance.

He has submitted a certificate from his treating doctor Dr. Ashim Desai which states;

‘Surgeon fees are not like market products which have fixed labelled MRP. Please do not compare surgeon knowledge & experience in terms of less amount. Any surgeon charges his fees according to his knowledge, skill, experience & operative success rate.’

Contentions of the Respondent Insurer (RI):

The Respondent Insurer has stated in Self Contained Note that out of total Claim amount of Rs. 136051/- they have deducted Rs. 101051/- and remaining amount of Rs. 35,000/- was paid. The major deductions were made on Professional Fees of the operating Surgeon and on Operation Theater charges. Out of Rs. 98000/- claimed for Surgeon fees, an amount of 80000/- was deducted as the quantum of the Surgeon fees are exorbitantly higher than the Standard Charges in the geographical area for identical or similar services. And the amount of bill was escalated for the purpose of profiting from the claim. All the above deductions were made in accordance of Definition No. 30 of the policy: “Reasonable and Customary charges means a charge for medical care which shall be considered reasonable and necessary to the extent that it does not exceed the general level of charges being made by others of similar standing in the locality where the charge is incurred when furnishing like or comparable treatment, services or supplies to individuals of the same sex and of comparable age for a similar disease, illness, medical conditions or injury.”

Similarly out of Rs. 25000/- claimed for Operation Theater charges an amount of Rs. 20000/- has been deducted on the same ground explained above.

Respondent Insurer has provided the Tariff in the neighboring Bombay Hospital for identical services which are as under:

Particulars Billed amount of VADT Nursing Home

Bombay Hospital Settlement Amt.

OT charges Rs.25,000/- Rs.3,700/- Rs.5,000/-

Professional charges Rs.98,000/-

Rs.20,000/-

Rs.18,000/-

Hence, all deductions were made as per policy definition no. 30 Reasonable and Customary charges and there is no scope of review of the claimed amount.


During the personal hearing on 28/04/2021(Online) both the parties reiterated their respective stand. The Complainant contended that as per treating Surgeon Dr. Ashim A Desai’s advice he underwent right Ear Stapedectomy surgery at VADT Nursing Home and settled his fees and Operation theater charges of the Nursing Home as per Bill. The deductions made by the Respondent Insurer is arbitrary and not as per the prevailing rates of the nearby hospitals. He is entitled to full reimbursement of his claim.

RI representative reiterated the stand taken in the SCN and in addition to that she informed that the operation is minor in nature and for that procedure Surgeon Fees of Rs 98,000/- is on a very higher side. At the same time the Operation Theatre Charges of Rs. 25000/- are also unrealistic and not at par with the other hospitals of the same or nearby locations. The Respondent Insurer further argued that the charges paid by the Complainant were on higher

side as prevailing rates in nearby location of Mumbai for similar surgeries in reputed hospitals/ nursing homes are much less than the amount paid. In support of their argument, the RI has produced tariff of Bombay Hospital. The RI further stated that they had already paid Rs. 35000/- on account of hospital bill and medicines.

During the hearing, the RI was asked to submit the comparative tariffs referred by them for our observation. Forum also took a net search for the probable cost for this type of surgery in Mumbai and observed that it is costing on an average Rs.94000/=. The copy of tariff of Bombay Hospital date is of 5 Nov.15. Based on that, forum finds that following amounts will be reasonable to consider for payment of claim of the year 2019. This approximately tallies with the probable expenses as found from the web search by deduction of non-payable items.

Particulars Billed amount of VADT Nursing Home Amount allowed by the forum S e t t l e d A m t . Balance amt payable

OT charges R s . 2 5 , 0 0 0 / - R s . 2 0 0 0 0 / - Rs.5,000/- R s . 1 5 0 0 0 / -

Professional charges R s . 9 8 , 0 0 0 / - R s . 5 0 0 0 0 / - Rs.18,000/- R s . 3 2 0 0 0 / -

Balance Payable Rs. R s . 1 , 2 3 , 0 0 0 / - R s . 7 0 0 0 0 / - Rs.23000/- R s . 4 7 0 0 0 / -

Award follows:

AWARD Under the facts and circumstances of the case, the Respondent is directed to pay to the Complainant Rs.47000/- towards full and final settlement of his complaint. The award is to be complied with within one month from the date of receipt of this award failing which it will attract interest at the bank rate plus 2% extra from the date of rejection of claim till the date of payment of this award.

The attention of the Complainant and the Insurer is hereby invited to the following provisions of Insurance Ombudsman Rules 2017: 17(6) the insurer shall comply with the award within thirty days of the receipt of the award and intimate compliance of the same to the Ombudsman. 17(8) the award of Insurance Ombudsman shall be binding on the insure

Dated: On 10th day of August, 2021 Pune VINAY SAH INSURANCE OMBUDSMAN, PUNE.

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, PUNE

(STATE OF MAHARASHTRA EXCEPT MUMBAI METRO) UNDER SECTION 16/17 OF THE INSURANCE OMBUDSMAN RULES-2017

OMBUDSMAN–VINAY SAH CASE OF MR. KANNAN NAIR V/S STAR HEALTH & ALLIED INSURANCE CO. LTD.

COMPLAINT NO: PUN-H-044-1920-0585 Award No IO/PUN/A/HI/ /2021-2022


Mr. Kannan B. Nair C1-505, Madhav Sankalp CHS, Khadakpada, Kalyan (W) – 421301 (M.S.)


P/141129/01/2020/000218 Group Medical Health Insurance Policy (M/s Praxair India Private Ltd.)

3. Policy period: 01/09/2019 to 31/08/2020

4. Sum Insured/IDV Rs.4,50,000/-



Mrs. S. Aarathy – Age: 26 years (M/s Praxair India Private Ltd.)

7. Name of the Insurer: STAR HEALTH & ALLIED INSURANCE CO. LTD.


Treatment taken was a cosmetic surgery and not payable as per policy terms & conditions.


10. Nature of complaint: Rejection of health claim

11. Amount of Claim: R.48,543/-

12. Rule of IO Rule under which the Complaint was registered:

13(1)(b)

13. Date of hearing/Place: 06.07.2021(Online )

Representation at the hearing

c) For the Complainant: Himself

d) For the insurer: Dr. Smita Sonawane


16. Date of Award: 10.08.2021

Contentions of the Complainant: Complainant and his family were insured with RI vide above policy for the period 01/09/2019 to 31/08/2020for SI of Rs.4.5 lakhs. His wife was admitted in V.G. Saraf Memorial Hospital, Ravipuram, Cochin on 18/09/2019 with complaints of enlargement of accessory breast tissue around the right axilla with associated tenderness and was diagnosed with Right sided accessory breast and after the surgical procedure, she was discharged on 23/09/2019. Reimbursement claim for Rs.48,543/- was lodged with the RI but RI has rejected the claim vide their letter dated 06/11/2019 on the grounds that the insured patient is admitted for accessory breast excision which is a cosmetic surgery. Consequent to rejection of the instant claim, insured has approached the Grievance Cell of the RI vide letter dated 28/11/2019 for reconsideration of the rejected claim but they have they have again repudiated the claim

citing similar reasons. Aggrieved with this situation, complainant has approached the forum for resolution of his grievance. He contends that how come a surgery conducted to remove any tissue due to pain is considered a cosmetic surgery. Contention of Respondent Insurer (RI): It is contended that as per the Outpatient Assessment Form issued by the treating hospital, the insured patient was diagnosed with Accessory Breast Tissue and she underwent excision of the same which is a cosmetic surgery and hence the claim has been rejected under Exclusion No.22 of the policy, which is reproduced hereunder: Exclusion No.22 – “The Company shall not be liable to make any payments under this policy in respect of any expenses what so ever incurred by the insured person in connection with or in respect of: Change of sex or cosmetic or aesthetic treatment of any description, Plastic surgery (other than as necessitated due to an accident or as part of any illness), all treatment for erectile dysfunctions.” In view of above exclusion, the claim was repudiated and communicated to the insured on 02/11/2019. Result of personal hearing with both the parties (Observations & Conclusions):

During the personal hearing on 06.07.2021 (Online), both the parties reiterated their respective stand. RI argued that the patient’s histopathology report was normal. Then considering her age, it clearly points towards cosmetic surgery. The complainant argued that his wife was having pain because of the accessory tissue. Its position was at the arms section because of which she was not able to move her hands freely. It was causing discomfort also. It was increasing day by day. In the hospital papers also in Discharge summary they have mentioned this fact in the column of Reason of admission as: ‘Enlargement of accessory breast tissue around the right axilla with associated tenderness’. Tenderness meaning is extreme sensitivity to pain, periodic swelling is also mentioned in the discharge summary. In view of this, it is not correct to say that the surgery was for cosmetic purpose. Non malignancy of the tissue alone cannot be a deciding factor to term it as ‘cosmetic surgery’. RI’s decision of repudiation on this ground is set aside. Payable amount as conveyed by RI is Rs.45,827/-. The deduction of Rs. 2,716/- from the claimed amount is found to be reasonable. Complaint Admitted. Award follows.

AWARD

Under the facts and circumstances, Respondent Insurer is directed to pay Rs.45,827/- to the complainant towards full and final settlement of this complaint.

The award is to be satisfied within one month from the date of receipt of this award failing which it will attract interest at the applicable bank rate plus 2% extra from the date of rejection of the claim till the date of payment of this award.

The attention of the Complainant and the Insurer is hereby invited to the following provisions of Insurance Ombudsman Rules 2017:

17(6) the insurer shall comply with the award within thirty days of the receipt of the award and intimate compliance of the same to the Ombudsman.

17 (8) the award of Insurance Ombudsman shall be binding on the insurers.

Dated: On 10th day of August, 2021 at Pune

VINAY SAH INSURANCE OMBUDSMAN, PUNE.


UNDER SECTION 16/17 OF THE INSURANCE OMBUDSMAN RULES-2017 OMBUDSMAN–VINAY SAH

CASE OF Mr. Karbhari B Wagh V/S The New India Assurance Co. Ltd., COMPLAINT NO: PUN-H-049-1920-0607



Mr. Karbhari B Wagh, Room no.4, Vrundavan Complex, Junnar Phata, Tal- Ambegaon.


142300/34/17/04/00000041 New India Flexi Floater Group Mediclaim Policy

3. Policy period: 25/07/2017 to 24/07/2018

4. Sum Insured/IDV Rs. 300,000/-



Mr. Karbhari B Wagh, 60 Years, Health Insurance for Govt. of Maharashtra Employees,

7. Name of the Insurer: The New India Assurance Co. Ltd.,


Delay in submission of claim documents more than 30 days.


10. Nature of complaint: Claim should be approved & condone the delay.

11. Amount of Claim: Rs.277,507/-

12. Rule of IO Rule under which the Complaint was registered:

13(1)(b)

13. Date of hearing/Place:

14. Representation at the hearing 22.07.2021(On Line hearing)

e) For the Complainant: Himself

f) For the insurer: Mr Pankaj



Complainant was covered under medical insurance policy for serving and retired employees of Maharashtra Govt. from Respondent Insurer (RI). The complainant was admitted in the Samarth Hospital, Pune from 20.12.2017 to 21.01.2018 for primary automatic failure, Adhesions Disease. Total claimed amount was Rs.277507/- He submitted his claim documents to MD India on 11.12.2018. He contends that as he was not completely recovered and also there was no responsible person in his home, there was a delay of 294 days to submit the documents. Hence the Respondent Insurer rejected the claim for delay in submission of claim. The complainant is requesting forum to intervene for settlement of full claim amount waiving the delay in submission. Contentions of Respondent Insurer (RI): The RI in their SCN dated 12.02.2020 gave their contention. The claim was repudiated as there was delay of more than 30 days in claim submission under clause no 11 which is mentioned below “The claim is repudiated as-Final claim along with hospital receipted original bills/cash memos claim form and documents as listed in the claim form should be submitted to the policy issuing office/TPA not later than 30 days of discharge from the hospital.” Result of personal hearing with both the parties (Observations & Conclusions):

During the personal hearing on 22.07.2021(through video-conferencing), both the parties reiterated their respective stand.

During the hearing the complainant narrated that due to the said ailment; he was not in a position to do anything. He was completely disabled. Only wife was there to attend to him. For 17 to 18 months he was completely bedridden. Somebody had to lift him. He could not

walk during those days. He was told that it was lung disease. But till the end, it could not be diagnosed. Now he is ok. After recovering he submitted the papers to RI, but they denied it saying it as delayed submission.

In view of the genuine reason for delayed submission of claim documents, this forum condones the delay and orders RI to process the claim and settle it within one month from the date of this order.

It is clear from the rejection letter that the RI/TPA is in possession of required original claim papers to process the claim.

Complaint allowed. Award follows:

AWARD Under the facts and circumstances, the RI is directed to pay Rs.277577/- less deduction as per policy terms and conditions, within available SI to the complainant, towards full and final settlement of the complaint.

The award is to be settled within one month from the date of receipt of this award failing which it will attract interest at the prevailing bank rate plus 2% extra from the date of rejection of the claim till the date of payment of this award.



17(8) the award of Insurance Ombudsman shall be binding on the insurers.

Dated: at Pune this 30th Aug 2021 VINAY SAH

Insurance Ombudsman, Pune



CASE OF MR. KISHAN CHAVAN V/S TATA AIG GEN INS CO LTD COMPLAINT NO: PUN-H-047-1920-0413



Mr. KISHAN CHAVAN PUNE


0260002010 00 Group Mediprime policy

3. Policy period: 01.01.2017 to 31.12.2017

4. Sum Insured 400000



Baby Samruddhi Chavan, (D) 5 yrs Foseco India Ltd. Shirur

7. Name of the Insurer: TATA AIG GEN INS CO LTD

8. Reason for repudiation/Partial Settlement: MIS REPRESENTATION/FRAUD UNDER SECTION 3 CLAUSE 1


10. Nature of complaint: Full settlement of claim amount



Rule 13 1 (b)

13. Date of hearing/Place: 25/05/2021; Online



b) For the insurer: Dr.Dhiraj Mhatre

15. Complaint how disposed: Dismissed

Brief facts of the case:- ● The complainant had taken Group Mediprime policy with Respondent Insurer The

TATA AIG GEN INS CO LTD, for self and his family for SI 4 lakh. ● He lodged a claim for his daughter’s hospitalization in Bhakti Hospital, Sanaswadi,

Shirur from 01.10.2017 to 07.10.2017 for Acute febrile illness with thrombocytopenia with lower respiratory tract infection. The total expenditure on hospitalization was Rs.31075/-

● The claim was repudiated under section 3 /clause 1 of the policy wordings stating that RI had found some discrepancies in the claim documents.

Contentions of the Complainant:- Complainant stated that he had submitted a claim for hospitalization of his daughter in Bhakti hospital, Shirur as she was suffering from Pneumonia. He had provided all evidence requested by RI in the form of documents/prescription/hospital bills/medicines bills to prove his claim is covered by the policy. Despite this, Respondent repudiated the claim pointing to certain discrepancies in the claim documents. Aggrieved by their decision, Complainant approached this Forum requesting intervention for settlement of full claim amount. Contentions of the Respondent Insurer (RI): Main points of their SCN are reproduced below:

‘On investigation of the claim under question, it was observed that there were major irregularities in the claim and hence was rejected vide letter dated 16.12.2017

Some of the Major Irregularities found in the Case 1. Treating Doctor Dr.S.R. Vyawahare’s signature on his Registration certificate, letter dated 7.10.2017 & Discharge card was not matching. 2. Insured IP No as per Hospital register was 1066. Another patient Ms.Kamal Kamble was given IP number-1065. Both were admitted on 1st oct.2020 (should be 2017). However, another patient-Ganesh Karve who was admitted after both of them (on 2nd October 2020 (2017)) was given IP no.1064. Surprisingly insured was given IP No 1064 as per final bill, Discharge card & Indoor case papers. 3. INR 500/- charged as Dr Bhushan Vidhate’s fee in final hospital bill. However, Dr Bhushan was not in Pune during the hospitalization period. As per his facebook posts, he was in Hyderabad at that time. In Hospital advertisement board, in various consultant’s list, Dr Bhushan Vidhate’s name was not there. In hospital website also, in various consultants list Dr. Bhushan Vidhate’s name is not there. 4. A cursory look at the indoor case papers, nursing chart show that they were written by one person at a stretch. When a person was admitted for 6-7 days, it is unlikely that the treating doctor/nurse was on duty for 24 hours a day during the course of admission. 5. Lab reports value are not noted in indoor case papers 6. In letter dt.7/10/2017, Dr. SR Vyawahare mentioned that pain in abdomen continued hence. Sonography was done on 5th October 2020 (2017). Whereas, as per ICP, abdominal pain was never there after 02.10.2017. 6. In statement to investigator, insured mentioned that patient was having motions prior to admission, however these symptoms are not there in indoor case papers (ICP). It was also told by the insured that the patient was suffering from Dengue but no dengue test was conducted as per the lab tests. 7. No pre-post consultations are submitted or mentioned by the insured during the investigation. 8. As per vital chart, patient had cough and temperature (100ᶿC) at 9am on day of discharge but still patient was given discharge at 12pm. Temperature recorded in ICP does not match with temperature noted in the vital chart. 9. Insured charged for X-ray for four times but as per ICP, X ray was advised only on admission. 10. In the letter to Ombudsman, insured has mentioned that due to financial issues, insured never paid the hospital bill, still hospital has issued bill paid receipt of Rs.20570/-dt. 7/10/2020 and lab receipt of Rs.6170/- dt.7/10/2020. In statement to investigator, insured mentioned that Rs.20570/- were paid by cheque.

● From the above observations it was clear that the claim is fabricated and fraudulent. Hence, they have rejected the claim under Section3 –General exclusions of the policy as quoted below: Fraud: If any claim in any manner dishonest or fraudulent or is supported by any dishonest or fraudulent means or devices whether by insured person or anyone acting

on behalf of insured person, then this policy shall be void and all benefits paid under shall be forfeited.

In addition to this, some more points in respect of the said insured and the doctor and the hospital are:

● The insured and his family members had registered three claims with RI. (2 claims settled)

● Bhakti Hospital, Sanaswadi, Shirur has been marked by Royal Sundaram General Insurance Co on their website for being involved in fraudulent/suspicious claims.

● Earlier, RI had rejected the claim of Ms Vidya Pawar from the same hospital in view of irregularities.

● As per Email from HDFC ERGO insurance company, Dr S.R. Vyawahare (treating doctor) was actively involved in suspicious activitie

Result of personal hearing with both the parties (Observations & Conclusions): During the online hearing, both the parties reiterated their respective stand. RI representative averred that before denying any corporate claim, they take opinion of 3-4 persons as they have to answer HR, broker etc. still they have denied this claim considering the extent of fraud involved. In the instant case, RI has repudiated the subject claim as supported by dishonest/ fraudulent means based on certain discrepancies observed in the claim documents, copies of which are submitted on record. On an analysis of the documents produced on record, it is observed that there are certain obvious discrepancies in the claim as pointed out by the Respondent. During the hearing also, claimant could not give satisfactory replies to these discrepancies. He pleaded innocent saying that it is all doctor’s doing. He doesn’t know anything. His child was not well. His wife took her to the hospital and she was cured there. Considering the fact that the patient/insured may not have hold on hospital papers, at least his payment particulars and the replies for the illness should have matched. Complainant submitted that as he did not have money, doctor told him to pay as and when possible and take back the cheque. This explanation is not convincing. In view of this, there is ample scope to infer that the documents seem to be fabricated and there are likely misrepresentations done by the complainant. In view of this, RI’s decision of rejection of claim on the grounds of misrepresentation, is not challengeable. Complaint is disallowed. Award follows:

AWARD

Under the facts and circumstances, the complaint stands dismissed in view of the discrepancies observed in the claim papers and mis-representation established from the documents submitted on record.

Dated: at Pune this 10th day of August 2021

VINAY SAH

Insurance Ombudsman, Pune


(STATE OF MAHARASHTRA EXCEPT MUMBAI METRO)

UNDER SECTION 16/17 OF THE INSURANCE OMBUDSMAN RULES-2017 OMBUDSMAN – VINAY SAH

CASE OF Mr. P. Sanju Kunjukoshy Vs. HDFC Ergo General Insurance Company Ltd.

COMPLAINT NO: PUN-H-048-1920-0460



Mr. P. Sanju Kunjukoshy 401 A Panchali CHS, Plot No.29, Sector 42, Kendriya Vihar, Navi Mumbai – 400 706


120100/12586/2018/A012950/PE01219468 Group Assurance Health Plan – Canara Bank

3. Policy period: 13/11/2018 to 12/11/2019

4. Sum Insured/IDV Rs.5 lakhs



Mr. Idicula Kunjukoshy – Age: 67 years Mrs. Saramma K. Koshy

7. Name of the Insurer: HDFC Ergo General Insurance Company Ltd.

8. Reason for rejection /Partial Settlement:

Patient had an h/o Benign Prostatic Hyper-plasia (BPH) since 2014 and not disclosed.


10. Nature of complaint: Wrongly rejected the claim.


12. Rule of IOR 2017 under which the Complaint was registered:

13(1)(b)

13. Date of hearing/Place: 14/06/2021, Online. Pune.


g) For the Complainant: Absent

h) For the insurer: Mr. Neeraj.

15. Complaint how disposed: Dismissed.


The Complainant is the son of insured who was insured with the Respondent Insurer (RI) under the above policy for a SI of Rs.5 lakhs for the period 13/11/2018 to 12/11/2019. It was a group policy offered to the customers of Canara Bank. The insured patient aged 67 years was admitted at Hiranandani Hospital on 06/07/2019 with complaints of abdominal pain, vomiting, giddiness, loose watery stools and was diagnosed with acute gastroenteritis with vertigo. After discharge on 09.07.2019, he filed a claim for Rs.48,996/-. The RI rejected the hospitalization claim stating that the insured patient is a known case of benign prostatic hyperplasia (BPH) since 2014 and this fact was not disclosed while filling the proposal form and hence as per policy terms and conditions, claim was repudiated. Subsequently RI cancelled the policy and a portion of premium paid was credited to his account.

Complainant then approached Grievance Cell of the RI and explained that the present claim was for Vertigo and not for any other medical condition of the insured patient and rejection of claim linking to pre-existing disease of BHP and cancellation of policy is not acceptable. Complainant further explained that this policy was bought through Canara Bank as an account (SB2766) holder without any medical test and at the time of buying the policy all medical issues were shared to the Bank manager. Complainant requested to the grievance officer to re-consider hospitalization claim. But RI stood by their earlier decision. Aggrieved with this situation, the complainant has approached the forum for redressal of his grievance. Complainant has demanded that if the company is firm on cancellation of policy, then he should be refunded the total amount of premium paid. i.e. 2 instalments.


The RI has mentioned in SCN that initially they had authorized a cashless claim for an amount

of Rs. 20,000/-. After receipt of the Internal Case Papers it was observed that insured patient

had history of BPH since 2014 and the same was not disclosed in the Proposal form at the

beginning of the policy in November 2017. Complainant was asked to provide documents of

past discharge summary of Heart disease, which has not been provided by the Complainant

and as a result, the cashless facility was withdrawn. In view of the incorrect declaration of the

material fact regarding benign prostatic hyperplasia since 2014 the reimbursement claim was

denied and policy was terminated after giving due notice to the Complainant.

The RI has submitted that son of the complainant vide declaration dated 08/07/2019 has

admitted the material fact that his father was taking medicines for BPH from 2014 onward

and complainant has further claimed that the present claim is completely different from the

previous illness. This is a case where a pre-existing condition was not disclosed in the proposal

form which directly relates to misrepresentation and thus action of rejection of claim and

cancellation of policy under the terms and conditions of the policy is justified.

Result of personal hearing with both the parties (Observations & Conclusions): A personal hearing was held on 14/06/2021 (Online) where RI representative reiterated their contention. The point of dispute here is rejection of current claim for AGE c Vertigo due to undisclosed ailment of BPH that was present before the inception of the policy. The complainant is not denying that his father had pre existing disease, but he is stressing on the fact that no medical test was required by the company both at the time of 1st purchase as well as at the time of renewal. He is also repeatedly mentioning that they are not claiming for any heart related issue or for previous prostate issue but their claim is for vertigo. Forum observes that the complainant is trying to portray that as no nexus exists between pre existing medical condition and the treatment taken in current claim, his liability of non-disclosure is not important. He must bear in mind that as this was non-medical policy, it was absolutely incumbent on the policy holder to disclose all prevailing medical condition at the time of filling enrolment form. Question of relevancy of this information is to be decided by

the insurer and not by the insured. RI has averred that had the good health declaration been answered in negative, they would not have issued the policy in the beginning. In view of this, it is clearly seen that the insured has deliberately suppressed a material fact, violating the principle of ‘Utmost Good Faith’ which is the basis of an insurance contract. Forum thus finds no reason to overrule RI’s decision of rejection. Award follows:

AWARD Taking into account of the facts and circumstances of the case the complaint is dismissed.

Dated: On 18th day of August, 2021 Pune

VINAY SAH INSURANCE OMBUDSMAN, PUNE.



CASE OF Mr.RAJENDRA P PANDHARPURKAR V/S UNITED INDIA INS CO LTD COMPLAINT NO: PUN-H-051-1920-0485



Mr. Rajendra P Pandharpurkar Amravati


120200/28/18/P1/03722787 Tailor made Group Health Policy(SBI)

3. Policy period: 01.06.2018 to 31.05.2019

4. Sum Insured Rs.200000



Rajendra P Pandharpurkar; 66 years State Bank of India

7. Name of the Insurer: United India Insurance Co Ltd

8. Reason for repudiation/Partial Settlement: Claim denied under clause 3.2 Reimbursement of MRI bill





Rule 13 1 (b)




b) For the insurer: Ms. Anita Harkare

15. Complaint how disposed: Dismissed


● The complainant was covered under a tailor made group health policy (SBI) meant for retired bank employees of SBI, with Respondent Insurer (RI), the United India insurance co ltd. Being aggrieved by rejection of mediclaim of Rs.6000/- which was a reimbursement of MRI bill of Rs.6000/- for shoulder pain, he approached the forum for justice.

● Insured was suffering from pain in left shoulder which is evidenced from MRI report dated 15.04.2019. Dr Kurve termed it as JOINT PAIN and advised to obtain MRI.

● The RI has rejected the claim under policy clause 3.2. He contended that as per policy, he is eligible to get upto 15% of sum insured for domiciliary treatment. That he has borne expenditure of medicine personally as it was very meagre and only MRI bill was submitted to RI for reimbursement.

● The complainant requested the forum to intervene for settlement of full claim amount.

Contentions of the Respondent Insurer(RI):-

As per SCN received, it is contented by RI that,

As per the complaint received from Rajendra P Pandharpurkar, he was diagnosed with joint pain, in left shoulder, took treatment and oral medicine on 15.04.2019. MRI bill was produced for reimbursement. The claim was denied under clause 3.2. The complainant is of the opinion that clause 3.2 has no relevance as domiciliary treatment expenditure is within specified limit of 15% of basic SI.

Clause 3.2 “Medical expenses incurred in case of diseases which need domiciliary treatment as may be certified by the medial practitioner shall be reimbursed to the extent of the 15% of basic sum assured. The cost of medicines, investigations and consultation etc. In respect of the domiciliary treatment, expenses shall be reimbursed for the period stated by the Registered Medical practitioner in prescription or 90 days whichever is earlier. If the treatment continues beyond 90 days, a fresh prescription has to be submitted, In case the doctor advised lifelong medicine for follow up after one year or six months, the validity of prescription would be 180 days.”


The Forum notes that the above policy covers the specific 63 named ailments under the Policy Clause No.3.2 (Domiciliary Hospitalization/Domiciliary Treatment). However, it is noted that the TPA as well as RI have used the correct policy exclusion clause no. 3.2 for denial, but the wordings of it, are different.

The complainant was therefore asked to indicate the exact number of disease out of 63 listed, in which his claim falls, for which he said, he does not have the list. The forum, therefore went through the list thoroughly and found that the joint pain or related investigations (MRI) are not falling under the said named 63 ailments.

Complaint therefore does not sustain.

Award follows:

AWARD Under the facts and circumstances, it is found that the decision of repudiation of claim needs no intervention. Complaint therefore stands dismissed.


VINAY SAH Insurance Ombudsman, Pune



CASE OF Mr. UMESH B CHAKKE V/S UNITED INDIA INS CO LTD COMPLAINT NO: PUN-H-051-1920-0390



Mr. Umesh B Chakke, Pune


1622012019484100000441709 Tailormade group mediclaim policy

3. Policy period: 25.04.2019 to 24.04.2020

4. Sum Insured 5,00,000



Mrs. Vaishali Chakke, 46 years Mr. Umesh B Chakke

7. Name of the Insurer: United India Insurance Co Ltd

8. Reason for repudiation/Partial Settlement: Claim occurred in the gap period of insurance renewal





Rule 13(1) (b)



a) For the Complainant: Mr. Umesh B Chakke

b) For the insurer: Mr. Mohan Girme

15. Complaint how disposed: Disallowed


The Complainant’s spouse, Mrs.Vaishali Umesh Chakke was admitted to Sahyadri Hospitals Ltd, Pune from 20.04.2019 to 23.04.2019 for the diagnosis of Right Anterolateral Pontine Infarct Left Trigeminal Neuralgia. The Complainant approached this Forum with a complaint against denial of his claim by the Respondent Insurer (RI), The United India Insurance Company Limited on the ground that the hospitalization of the insured patient falling in gap period that is after the expiry of the previous policy and before the renewal of the next policy, hence, not payable as per policy terms and conditions Clause 2.12.


The Complainant submitted that he had availed the subject policy with the Respondent, United India Insurance Co Ltd. which was issued to Bank of Maharashtra account holders, and was paying the premium for himself, wife regularly since April 2017. He preferred a claim with the Respondent for the hospitalization of his wife, Mrs. Vaishali Umesh Chakke in Sahyadri Hospital from 20.04.2019 to 23.04.2019 for the treatment of a Neurological issue for a claim amount of Rs.29,653/-. However, the claim was repudiated due to the date of admission falling in the gap between two policy periods, so not admissible as per the terms and conditions of the policy. The complainant explained that his previous insurance policy period was from 20.04.2018 to 19.04.2019 (Policy No.1622012018484100000481912). Due to a public holiday on 19.04.2019, he deposited a premium amount in the Bank of Maharashtra on 20.04.2019 but due to some problem on the part of the bank, they could not renew the mediclaim policy on 20.04.2019 and was renewed with effect from 25.04.2019. The Complainant submitted the clarification letter dated 13.06.2019 from the Bank of Maharashtra which states that the insured visited them on 20.04.2019 for renewal, but due to some technical error in the system could not renew the policy on that day. They tried online also but could not do the renewal. On 21.04.2019 it was Sunday, 22.04.2019 Bank’s Official was on leave, and again on 23.04.2019 due to the election, there was a holiday. Hence the policy was punched by the Bank on 24.04.2019 and the premium was debited on 25.04.2019. In this way, policy renewal was delayed and the policy was renewed from 25.04.2019. Meanwhile, Complainant’s wife was to be admitted to the hospital in an emergency state on 20.04.2019. However, the claim reported for the same was repudiated by the Insurer stating the period of hospitalization falling in the gap period of the policy renewal hence not payable as per policy terms and conditions. Since, the Complainant had approached the bank on the date of renewal and had paid the premium on 20.04.2019, not agreeing with the denial, requested the Forum to intervene for settlement of the claim.


It was contended by the Respondent in the SCN submitted that the Complainant had lodged the claim for the hospitalization of his spouse from 20.04.2019 to 23.04.2019. While processing the claim, on scrutiny of the policy documents, it was observed that the hospitalization period fell in the gap period because the insured’s earlier policy expired on 19.04.2019 and the policy was renewed with effect from 25.04.2019. Hence, the claim is not admissible as per the policy terms and conditions under clause 2.12 which reads as 2.12 Grace period: A grace period of 30 days is permissible to effect renewal of policy to protect the benefits of continuity, subject however that no claim shall be admissible for any event arising during the period immediately after the expiry of existing policy and renewal thereof. This grace period is liable for change as and when regulatory changes are effected by IRDAI. Given the facts, Respondent stood by their decision of the denial of the aforesaid claim being made as per terms and conditions of the policy.

Forum’s Observations/Conclusion:

On scrutiny of the documents produced on record it is observed that the Complainant on the renewal date of the policy that is on 20.04.2019 had paid the premium to Bank of Maharashtra through which the policy was issued to him. However, as alleged by the complainant, due to technical error and other issues, Bank could not deposit the premium in time and hence the policy was renewed after a gap of five days i.e. on 25.04.2019. Since the date of admission of the insured patient falls during the gap period of the policy, Respondent denied the claim as per above mentioned policy clause no.2.12. In the instant case, Forum directed the Respondent to submit the procedure followed by the Insured and Bank for renewal of the subject policies.

RI informed that they have given access to the bankers to deposit the premium amounts on receipt of request from the insured public in their (RI’s) bank account and issue the renewal policies. On specific enquiry with the incharge of bankassurance business being looked after at Pune, he clarified that without a specific request at every renewal, bank suo moto, does not debit the premium amount from their insured customers.

In this case, the policy was expiring on 19.04.2019 and it was known beforehand that 19.04.2019 is a bank holiday. As such, policyholder should have taken care to pay premium before expiry of the policy, not afterwards. It is also seen that his 1st policy of 17-18 had expired on 18.04.2018 which he renewed on 20.04.2018.

Bank has given a letter explaining the reasons of delay. They write that the customer visited branch for renewal of policy on 20.04.2019 but site was not getting open due to some error. If that was the case, they should have contacted the company with written mail for error resolution as per laid down procedure. This procedure was also given a go by.

In such a scenario, RI is not to be blamed for late renewal of the policy causing no insurance cover at the time of his wife’s hospitalisation and resultant denial of the claim.

Hence, the decision of the respondent does not call for any intervention and consequently no relief can be granted to the complainant.

Award follows:

AWARD Under the facts and circumstances, it is found that the decision of repudiation of claim needs no intervention. Complaint therefore stands dismissed.

It is particularly informed that in case the award is not agreeable to the complainant, it would be open for him/her, if he/she so decides to move any other Forum/Court as he/she may consider appropriate under the Laws of the Land against the Respondent Insurer.


VINAY SAH Insurance Ombudsman, Pune.


(STATE OF MAHARASHTRA EXCEPT MUMBAI METRO) UNDER SECTION 16/17 OF THE INSURANCE OMBUDSMAN RULES-2017

OMBUDSMAN– VINAY SAH CASE OF MRS. VARSHA RAMESH JOSHI V/S CHOLAMANDALAM MS GEN INS CO LTD

COMPLAINT NO: PUN-H-012-2021-0072 Award No IO/PUN/A/HI/ /2021-22


Mrs.Varsha Ramesh Joshi Thane


2876/00051535/000001/000/00 Group Health Insurance

3. Policy period: 27.02.2020 to 26.02.2021

4. Sum Insured (SI) Rs. 500000



Mrs.Varsha Ramesh Joshi,61 yrs Same as above

7. Name of the Insurer: Cholamandalam MS Gen Ins Co Ltd


Non disclosure of longstanding HTN


10. Nature of complaint: Settlement of claim amount



Rule 13 1 (b)

13. Date of hearing/Place: 14/07/2021; online


i) For the Complainant: Mr. Ramesh Joshi-h/o complainant

j) For the insurer: Mr. Abhijit Santikar & Dr. Prabhu

15. Complaint how disposed: Allowed partially


• The complainant had taken Group Health Insurance Policy with Respondent Insurer (RI) Cholamandalam MS Gen Ins. Co Ltd for self for SI of Rs.5 lakhs. She lodged a claim of self-hospitalization in Manisha Universal Multispecialty hospital, Thane from 04.07.2020 to 10.07.2020 for Covid 19 positive and k/c/o Hypothyroidism. The total expenses on hospitalization was Rs.166212/-

• The claim was repudiated by RI stating that the insured patient was k/c/o of hypertension since 15 years as per the history recorded in the consultation papers,

• The complainant has briefed her case that she was suffering from Covid 19 positive and her admission in the hospital was not for hypertension. Due to Corona she was suffering from blood pressure problem and accordingly had taken the treatment.

• She is requesting forum to intervene for full settlement of claim amount.

Contentions of the Respondent Insurer (RI):-

As per the SCN received,

The claim was repudiated on the right ground as per the policy terms and condition. It is submitted that as per the repudiation letter the ground of repudiation

“On perusal of the documents, it was observed that the insured patient was a k/c/o of hypertension since 15 years as per the history recorded in the consultation papers this information was not disclosed in the proposal form while proposing for insurance. In view of this non disclosure of material information as per F: General condition-4.9, the contract of insurance becomes void and no claim is payable under this policy”


Upon hearing contentions of both the sides and on perusal of documents submitted on record, forum has following observations.

1. The complainant had filed application before this forum stating that the discharge card mentions about her history of hyperthyroidism only and it is not hypertension (HTN) as wrongly interpreted by the RI. However, it is revealed from the investigation carried out by the RI that the patient insured has accepted in writing that she had HTN since 15 years. Also there is one consultation report from Ashwini Hospital dt. 09.04.2004. Consultation was for edema foot. Anti hypertensive medication changed to tab. Tenormin and Natrilix. Complainant then further contended that this hospitalization was not for HTN but for Covid and because of covid her HTN problem aggravated.

2. This being the first year of the policy, the HTN has two years waiting period. It cannot be denied that patients need extra care in covid conditions who are having co-morbidities like HTN. As agreed by the complainant herself due to covid she suffered HTN problem also.

3. The RI has not produced the copy of proposal form to establish the fact of non-disclosure from the complainant’s side.

In view of the above discussions, it can be inferred that the HTN contributed to the covid conditions and ultimately on hospital expenses also, forum took a view to deduct 50% of the

expenses from the admissible claim amount against the expenses due to HTN as it falls under waiting period and to pay remaining 50% for the covid treatment.

Complaint thus admitted partially.

Award follows:

AWARD

Under the facts and circumstances, Respondent Insurer is directed to calculate admissible amount for claim of Rs. 1,66,212/- less non-medicals as per policy terms, and pay 50% of the calculated admissible amount to claimant towards full and final settlement of the complaint.

The award is to be settled within one month from the date of receipt of this award failing which it will attract interest at the prevailing bank rate plus 2% extra from the date of rejection of the claim till the date of payment of this award.



17(8) the award of Insurance Ombudsman shall be binding on the insurers.

Dated: On 18th day of August, 2021 Pune VINAY SAH INSURANCE OMBUDSMAN, PUNE