'SMOKING DID NOT CAUSE PNEUMONIA'
Mumbai: An insurance company and a third-party administrator will have to pay Rs 69,000 compensation to a central Mumbai resident after wrongly repudiating his claim on the ground that his pneumonia was caused due to alcohol and smoking.
Holding United India Insurance Co Ltd and Raksha TPA Pvt Ltd guilty of adopting unfair trade practice, a consumer forum directed them to also pay the insured amount of Rs 1.44 lakh. "The opposite parties forgot to note that the complainant was not hospitalized for using alcohol. The complainant was hospitalized for acute pneumonia and not for use of alcohol. The exclusion clause does not apply to the present case and the opposite parties cannot take shelter of this clause and repudiate the mediclaim," the forum said.
The insurance company came up with an individual health insurance policy in August 2008. The sum assured to the complainant, Shantilal Jain, was Rs 4 lakh and was renewed by him from time-to-time.
Jain was hospitalized as he was suffering from acute pneumonia on February 8, 2010. Hospitalized for 12 days, he incurred an expense of Rs 1.44 lakh. In September 2010, the TPA told him the claim was not tenable under a policy clause. Jain said the clause was wrongly interpreted and filed a complaint in November 2011. The forum passed an ex parte order as the TPA and insurance company did not file replies.
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