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Man’s medical claim rejected after wrong report, insurance firm, hospital told to pay compensation

Indian Express 2019-08-11 09:14:28

Dalip Kumar of Himachal Pradesh purchased a medical insurance plan under the name “ProHealth Accumulate” of Cigna TTK Health Insurance Company which was valid from June 2, 2017 to June 1, 2018.


The Consumer Forum directed an insurance firm to pay Rs 34,819 to a Himachal Pradesh resident for rejecting his medical claim, along with asking Fortis hospital to pay Rs 35,000 to the complainant, and deposit Rs 1 lakh in the consumer legal aid account for giving a wrong report of the patient which led to rejection of medical claim.

The forum in the judgment released Friday held, “…OP-3 (Fortis) has definitely practiced unfair trade practice and firstly submitted the opinion that he was treated for diabetes also along with chest pain and hypertension and diabetes is such a disease which is not curable, but, can be controlled. If on 3.6.2017 complainant was a patient of diabetes, how the own doctor of OP-3 furnished a report on 14.3.2018 that he had never been a patient of diabetes. It is ridiculous one. The claim of the complainant was denied by OPs 1 & 2 (Cigna TTK Health Insurance Company) as per report of OP-3 (Fortis)which was not correct…”

Dalip Kumar of Himachal Pradesh purchased a medical insurance plan under the name “ProHealth Accumulate” of Cigna TTK Health Insurance Company which was valid from June 2, 2017 to June 1, 2018. On June 3, 2017, he felt pain in left side of chest radiating from left shoulder and arm, got himself admitted with Fortis Hospital.

He was discharged the next day and he paid a bill of Rs 34,819. Kumar then submitted the claim to his insurance firm but it was rejected on the grounds that he suffered DM diabetes and CAD, which were pre-existing. However, later Kumar obtained a certificate from Fortis stating that he was not suffering from any diabetic disease. After his claim was not approved by the insurance firm even after sending a legal notice, Kumar filed a formal case at Consumer Forum of Chandigarh.

Cigna TTK Health Insurance Company in reply submitted that the complainant had suffered pre-existing disease prior to the policy and he was having diabetes or pre-diabetes conditions for the last six months which facts were suppressed by him at the time of purchase of policy, and thus the claim was rejected.

On the other hand, Fortis hospital has also submitted separate reply and claimed that complainant was admitted, treated and was discharged and it has no concern with the allegations made in the consumer complaint.

After hearing the arguments the forum held that the complainant even has made a reference that after the treatment other tests got done by him from the pathological lab which shows his sugar level was within normal limits. Hence, he had not concealed any pre-existing disease.

Whereas Fortis had asserted in its reply that diabetes mellitus was informed by the complainant himself while their own record shows, after their examination complainant was found to be patient of diabetes mellitus, which is a contradictory reply, and since there was no concealment of pre-existing disease, therefore, the claim was wrongly rejected by the insurance firm.

“…complainant was treated for diabetes mellitus was on the disclosure of such record in the discharge slip etc. of OP-3 (Fortis)…it was the own diagnosis of OP-3 for which complainant was treated. In order to escape from liability, OP-3 (Fortis Hospital) has taken inconsistent, contradictory and paradoxical stand that they were told so by the complainant at the time of admission, while their own record shows, it was their own diagnosis…The complainant had furnished the affidavit that he had not disclosed such disease to OP-3 and rightly so…’

The Forum thus ordered the Cigna TTK Health Insurance Company to pay Rs 34,819 to Kumar along with 9 percent interest from date of rejection of claim which is July 29, 2017, till realisation. While the Fortis hospital has been directed to pay Rs 35,000 to Dalip Kumar as compensation and litigation cost.

Meanwhile, the forum also imposed a cost of Rs 1 lakh on Fortis Hospital, directed to be deposited in the Consumer Legal Aid Fund.