Berating the Oriental Insurance Company for denying a medical claim on grounds of alleged use of alcohol, the Ernakulam District Consumer Disputes Redressal Forum has directed the public sector insurance company to pay a compensation of ₹25,000 to a mediclaim holder.
The forum while directing the company to process the claim of medical expenses in a month, reminded the company that as the insurance companies were service providers, they were bound to respect persons and provide proper service to the insured persons. Terming a person alcoholic on untenable grounds could not be accepted.
The Supreme Court had observed in its various judgments that insurance companies could not repudiate a claim on flimsy grounds. The denial of the claim in this case relying on a letter without any further probe by the company was to be taken as “a negative attitude” towards the judgments of the Supreme Court, the forum noted.
The forum made the observations while allowing a complaint filed by Peethambaran from Kottayam questioning the denial of his medical claim. The holder of a ₹4-lakh mediclaim policy covering a period from January 14, 2015 to October 13, 2016, he was hospitalised following a bodily injury suffered by him in August 2016 in a fall. While he had initially undergone treatment at a clinic at Nagampadam, Kottayam, he was later moved to the Brain and Spine Centre Hospital, Vaikom.
The company rejected his claim of ₹91,000 on the ground that he had consumed alcohol on the date that he had fallen down. The insurance provider contended that it was revealed in a letter given by the clinic that had initially treated him.
The forum observed that the letter could not be treated as a letter of reference. It was seen as written by someone on behalf of a doctor, whose name and qualification were not shown. The insurance company had erred in jumping to the conclusion that the complainant was an alcoholic. The letter was a trump card to co-relate the disease of the complainant with the exclusion clause in the policy, under which a claim could be rejected on ground of an accident due to the use of intoxicating substances or alcohol.
The report of the neurosurgeon who had treated him at the hospital in Vaikom would prove that the disease of the complainant was not one that originated spontaneously by an accident. It was a clear case of arbitrariness on the part of the the insurance company, the forum observed.
