Insurance Co directed to compensate for denying medical claim

New Delhi, Aug 17 (PTI) A District Consumer DisputesRedressal Forum here has directed an insurance company tocompensate a woman for denying her mediclaim of Rs 64,705,observing that the rejection was unwarranted and devoid ofmerit. "When the treatment is undertaken by the unfortunateinsured, the insurance company takes a somersault andimmediately takes up the terms and conditions of the policywhich admittedly were not supplied to the insured at the timeof inception of the policy," the forum observed while awardingRs 8,000 compensation to north Delhi resident Vandana Dalmia. "The insured feels cheated at the hands of insurancecompany," the forum headed by President K S Mohi said. "The insured seldom gets the terms and conditions at thetime of inception of the policy or any subsequent thereto. Butthe insurance companies, in order to evade their liability,press into service their terms and conditions when the claimis filed," the forum, also comprising members Subhash Guptaand Shahina, observed. "We are of the considered view that the repudiation ofclaim of the insured by the insurance company were whollyunwarranted and devoid of any merit and therefore, itconstituted deficiency in service," it said. It also directed the award of Rs 64,705 with interest atthe rate of 6 per cent from the date institution of thecomplaint till payment, besides another Rs 8,000 towardsharassment mental agony loss of time and litigation cost. According to the complaint, Dalmia was admitted to ahospital for liver-related (Lap Cholecystectomy) treatment onFebruary 7, 2011 which cost her Rs 64,705. However, the medical claim towards her hospitalisationand treatment was rejected by Oriental Insurance Company Ltd,saying as per the terms and conditions of the policy taken byDalmia, the disease suffered by her could not be covered inthe first year of the policy. Dalmia further alleged that the insurance company whileissuing the policy had never apprised her about any suchcondition and had not even supplied the policy with allegedconditions and clauses as they were claiming. The insurance company claimed that as per terms andconditions of the policy, they were not liable for any claimand prayed for the dismissal of the complaint. "The insurance company has miserably failed to establishas to by which mode (it had) supplied the terms and conditionsto the insured. The law is now well settled which lays downthat the insurance company cannot take shelter under theumbrella of terms and conditions unless the same were dulyfurnished to the insured," the forum observed. PTI RRT AGARC