Discover the right solution in case insurance claims are wrongfully rejected

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Each and every customer who has a grievance may not find it possible to keep fighting for his/her rights. The consumer forums can only redress grievances of those who are approaching them in a timely manner. Until and unless there are changes in the attitudes and perceptions of the authorities, the system will keep lagging in this aspect. In a major regulation, the East Delhi Forum has asked the Government to come up with a solution for the wrongful rejection of insurance claims.

In a recent case, a woman was already pregnant for 6 months when she was struck by high fever and immense pain. She got admitted to a Noida hospital and doctors discovered that there was a perianal region swelling for at least 4-5 days which gradually became a perianal abscess. The woman required an operation and was in hospital for around 5 days. The bill amount was a little more than Rs. 40,000 and there were receipts for the payment which was made in cash. This woman was covered under a mediclaim plan from United India Insurance and filed a claim for reimbursement along with all documents and other bills. The claim was processed via Media Assist TPA and eventually turned down on grounds that the documents given were manipulated and fabricated ones. There were no reasons officially provided for substantiating this basis for claim rejection.

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This woman then filed her complaint to the East Delhi District Consumer Forum with the allegation that the rejection was a service fault and unfair practice. She also wanted reimbursement of her costs with compensation, costs of litigation and interest. The forum stated that the proof burden lay on the insurer for backing up allegations of documents being fabricated and illegal although the company did not even contest the woman’s complaint. Thus, the forum came to the conclusion that rejecting the claim was wrong on the part of the company.

Also Read:  Reasons Behind Rejections of Insurance Claims

Through the order passed by N A Zaidi, the presiding officer along with Poonam Malhotra on behalf of the bench, the claim was directed to be paid in tandem with the interest of 10%. The insurer also had to pay Rs. 25,000 as compensation along with Rs. 6,000 in litigation costs. These were eventually drawn from the salary earned by the individual who had turned down the woman’s claim.

The forum observed that wrongful rejection of claims was on the rise on grounds that were not solid or even without any grounds for the same. The insurance companies have to be careful that such things do not happen and officials who indulge in such wrongful practices should be punished by removing the interest, compensation and other costs from their remuneration. The landmark order issued by the forum was dispatched to the secretary, department of finance, Government of India and also to the United India Insurance Chairman for taking necessary steps to avoid the harassment of customers. Here’s hoping that the Government and insurers take these corrective measures in order to prevent wrongful rejection of insurance claims and prevent customer harassment.

We at Insurance Samadhan help aggrieved clients to correctly represent their case to the Consumer Forum in getting their rightful claim. For further details visit https://www.insurancesamadhan.com

Shailesh Kumar

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