6 days ago
Consumer forum in Coimbatore directs insurance firm to settle denied medical claim
Coimbatore: The district consumer redressal commission recently directed a public sector undertaking (PSU) insurance firm to reimburse a customer's medical claim of Rs9.43 lakh, which was earlier denied citing that the treatment was not covered.
According to an official source, the verdict was delivered on a petition submitted by P Nagarajan, a retired special sub-inspector of police, and his wife Nagaveni, of Singanallur, against the insurance firm that was responsible for disbursing medical benefits under the New Health Insurance Scheme (NHIS).
In their petition, the couple said they were entitled to cashless treatment up to Rs20 lakh for specified procedures under the scheme.
"Nagaveni was hospitalized on several occasions in 2022 for aneurysm-related treatment, incurring an expenditure of Rs16.98 lakh. However, only around Rs3.20 lakh was reimbursed. One of the claims was denied with a remark 'treatment not covered'," the source said.
Since a significant portion of the expenses remained unpaid even after submitting all original bills and medical records through proper channels, the couple were forced to arrange funds through personal loans and general provident fund withdrawals to meet the medical expenses, the source said.
The couple, in their petition, claimed that the insurance firm hadn't given them an opportunity for clarification before denying or reducing the claim amount. In their plea, they sought reimbursement of the medical expenses with 18% annual interest from February 24, 2022, along with a compensation for the mental agony they suffered.
In its ruling, the commission, comprising president R Thangavel and members P Marimuthu and G Suguna, directed the insurance firm to reimburse the eligible medical expenses of Rs9.43 lakh. It was also ordered to pay a compensation of Rs10,000 and another Rs5,000 towards the cost of legal proceedings.
