My brother’s health insurance claim was rejected by United
India Insurance Co, Divisional Office, Regional Office and also Head Office.
Insurance Ombudsman, Ahmedabad also upheld rejection of claim. Following five
reasons were communicated in piecemeal for rejection:
[a]. Late intimation of hospitalization by 5 days [clause 5.3 of policy]
[b]. Any
kind of Ayurvedic treatment is not payable as per policy terms and conditions
[no clause mentioned]
[c] Claim is within 2 years of
no-claim period [clause No. 4.3 of policy]
[d]. Indoor treatment not required for this operation.
[e]. Bill for Rs.6500/- has no number.
Under my guidance, my brother filed RTIs with Insurance Co
and Ombudsman office, both of which could not substantiate and produce basis on
which these reasons were assigned for repudiation of claim.
Armed with RTI replies, my brother filed consumer complaint
with Gandhinagar District Consumer Forum on 20-12-2013 . The forum upheld claim and awarded
Rs.15036/- including claim amount, with interest and compensation of Rs.3000/-
and expenses Rs.2000/- per its judgement dated 03-04-2014 . Insurance Company had practically
no say, since claim in complaint was fully substantiated with documentary evidence
procured through RTI. Insurance Company and Ombdusman were exposed for
mischievous rejection of claim.
My brother’s regulatory complaint with IRDA for violation of
its directives under IRDA Act is being followed up, so that in larger public
interest, such insurance claims are not rejected on unsubstantiated grounds.
080514
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