A consumer forum has held that insurance companies must pay medical claims even when a person opts for medical treatment without hospitalisation.
Hearing a complaint filed by Thane resident Abhay Bharad for non-payment of his mediclaim, the consumer forums earlier this week directed Oriental Insurance Company to pay his medical expenses of `93,800 with nine per cent interest from August 2010 along with compensation of `9,000.
Mr Bharad had moved the consumer forum after the insurance company refused to reimburse his medical expense stating that since his father took the treatment in the form daily sittings and was not admitted to a hospital.
Mr Bharad said, “In 2005, when I was an employee with Systime Global Solutions, a software firm in Navi Mumbai, the company had provided me with a medical insurance policy which provided an medical cover for my family too. Hence in 2009, when my father Arun Bharad (62) was suffering from a knee ailment, I contacted Kartysan’s health care clinic in Bangalore for their treatment. However they directed me to one of their branch in Andheri for the treatment. So, my father started with a radiotherapy treatment, which he completed in 21 sittings. The whole treatment costed (sic) me around `93,800. But when we claimed for reimbursement, the company refused to clear my claims. After several attempts to communicate with the company failed, I approached the consumer forum in August 2010.”
Challenging Mr Bharad’s claims before the consumer forum, the insurance company reiterated its stand that since the claimant’s father was not hospitalised, the company was not bound to pay the required amounts. Advocate Sharmista Gandhi, who appeared for Mr Bharad said, “We pointed out that radiotherapy is a type of treatment and nowhere in the company’s clauses it was mentioned that the expenses for a radiotherapy without any operation or hospitalisation will not be reimbursed. So it was mandatory for the insurance company to reimburse the medical expenses.”
After hearing the arguments from both sides, the forum concluded that it is the insurance company’s duty to pay for the medical expanses irrespective of type of the treatment. The forum directed the company to pay back the medical expense of Rs 93,800 with nine per cent interest from August 2010 to Mr Bharad along with Rs 4,000 as the compensations for mental agony and Rs 5,000 against the cost incurred by the complainant for filing a complaint before the forum.