District Consumer Commission directs Insurance company to reimburse over Rs 1.88 lakh medical claim of Delhi man

New Delhi: The District Consumer Disputes Redressal Commission directed Oriental Insurance Company to reimburse a medical claim amount of more than Rs 1.88 lakh along with a compensation of Rs 7,500 for deficiency in services to a policyholder.

The direction of the District Consumer Disputes Redressal Commission (East Delhi) came on the man’s complaint that the amount was not paid to him despite submitting a claim of Rs 1,88,729 along with requisite documents to Oriental Insurance Company Ltd in 2017.

The commission, comprising President S S Malhotra and Members Rashmi Bansal and Ravi Kumar, in a recent order, noted that the complainant’s wife was taking treatment at AIIMS and the raised claim was not disputed by the insurer.

It rejected the company’s arguments that the complainant did not submit the requisite documents.

“Fact otherwise is well proved that the complainant has filed all the necessary documents along with the complaint and exhibited all the documents. Therefore, it appears to the commission, that the contention that the complainant did not cooperate or did not furnish the document/details appears to be an afterthought,” the commission said.

Stating that not reimbursing the claim amounted to deficiency in services, the commission directed Oriental Insurance to pay the amount with interest along with Rs 7,500 as compensation and Rs 5,000 as litigation costs.

Medical Dialogues team had earlier reported that the Madurai bench of Madras High Court reiterated that a claim for medical reimbursement cannot be rejected merely because the treatment was undertaken in a non-networking hospital. "The issues regarding the settlement of the medical claim are no more res-integra in respect of the treatment undertaken in a non-network hospital. Several orders have been passed by the Courts to settle the medical reimbursement claim and not to reject the same merely on the ground that the hospital is not falling under the list of network hospitals," noted the HC bench comprising Justices SM Subramaniam and V Lakshminarayanan.