Surat: The Surat Consumer Disputes Redressal Commission (Additional) has ordered an insurance company to pay Rs 4,50,900 to the family of a deceased person whose five claims for cancer treatment were rejected. The insurer had rejected the claims saying the treatment could have been taken on OPD basis and day care procedures were not covered. The court lambasted the company and observed that ‘it was necessary for the patient to remain in hospital in a serious disease like cancer'.
The case relates to Navinchadra Patel, a resident of Barmorli village in Surat. Patel died on Oct 4, 2019, after being treated for cancer for six months. Before his death, five insurance claims worth Rs 4,50,900 were filed with SBI General Insurance Company Ltd, which were not cleared by the firm. Patel's wife, Bharti Patel, and his children, jointly filed a complaint on Dec 2, 2019, with the consumer court.
According to it, Patel had a family floater policy for Rs 5 lakh from Sept 8, 2018, to July 7, 2019. He was treated as an indoor patient at Metas of Seventh Day Adventist Hospital and diagnosed with non-Hodgkin's lymphoma on April 4, 2019. He was treated there for Rs 2.90 lakh in expenses and discharged. After that, he spent Rs 10,900 on various medicines.
Patel got chemotherapy and other treatment three times at the hospital between April and June 2019. He paid Rs 50,000 each time. He filed five claims for a total of Rs 4,50,900 for these. The insurer rejected the first four claims and did not give a status for the last one.
As the case reached the consumer forum, the advocate for the insurer said that ‘the claims were rejected under the terms and conditions clause. There is no unfair trade practice in rejecting the claim.'
The insurance company argued that treatment could have been taken on OPD basis. Treatment given to Patel was not included in the ‘Day Care Procedure' list for the policy. So, it was not liable.
The complainant presented a reference from the West Bengal Consumer Disputes Redressal Commission and produced a doctor's certificate. The certificate read: ‘Patient is under doctor treatment for chemotherapy, and it does not require admission for treatment. It can be transfused as a day care procedure.'
After hearing both parties, the court observed: "As per the certificate of the doctor, the patient was not required to get admitted. But looking at the chemotherapy treatment for a serious disease, the treatment was given in the hospital with proper care. This is a proper procedure. The claim rejected over the ‘OPD base' reason shows a defect in service by the firm. It is proven that the firm adopted unfair trade practices as the complainant is liable to receive the claim money."
The commission ordered the insurance company to pay Rs 4,50,900 with 8% interest from Dec 2019 and Rs 5,000 for harassment and application expenses.