Insurance claim's rejection due to `delay' not alright





`Treatment Went On For A Yr After Hospitalization'

A consumer forum has ruled in favour of a woman whose insurance claim was rejected by her insurer because it was filed 416 days after hospitalization instead of within the 30-day deadline.

The forum found that the complainant was under continuous treatment for her injury for more than a year.

It recently chastised National Insurance Co Ltd for repudiating the claim on technical grounds that "cannot be held as just and proper". "The insurance company adopted (an) unfair trade practice," said the South Mumbai District Consumer Disputes Redressal Forum, while directing the firm to pay Worli-based Jyoti Raut the insurance amount of Rs 39,439 along with compensation of Rs 12,000.

Raut was admitted in hospital on February 9, 2010, after she had a fall. When she was discharged the next day, Raut informed the insurer about the fall and the need for hospitalization and requested it for a claim form. She alerted it that as her treatment was on-going she would file the claim upon its completion. This point was iterated in letters on March 9, 2010, and March 7, 2011.

On April 25, 2011, Raut sent a letter claiming expenses incurred on the treatment that continued till March 31, 2011.

Two months later, however, the company repudiated the claim on the ground that the papers were not submitted within 30 days from the completion of the hospital treatment.

Raut lodged many protests with the insurer but when they were ignored she filed a complaint before the forum on July 11, 2012. The insurer, in response, argued there was no evidence to prove her continuous treatment till March 2011. "The last receipt of the doctor's clinic is dated September 9, 2010. It shows the treatment was completed," the company claimed.

The forum however pointed to bills showing that Raut had purchased medicines "on doctor's advice" on five different dates till February 2011.

"The evidence shows the complainant was under treatment till the end of March 2011 and that she incurred an expenditure of Rs 39,439 on treatment," it said.

It observed that Raut had informed the insurer that the doctor had advised her to continue treatment till March 2011. Thus, "it cannot be said that there was delay in submitting the claim on the part of the complainant," the forum said.