The Dakshina Kannada District Consumer Disputes Redressal Forum has ruled that wherever the insurance policy condition is not clear and has more than one interpretation, the interpretation that is beneficial to the consumer should hold good.
In a recent case, the forum held that “the purpose behind issuing an insurance policy should be taken into consideration. The policy is obtained for the benefit of the insured and not to the insurer.” In this case, the forum asked the insurance company to honour a claim for Rs. 16,956 and awarded compensation of Rs. 5,000 to policy holder Savitha Umesh of Kodial Guthu here.
Ms. Savitha questioned the decision of New India Assurance Co. Ltd. to repudiate her claim saying that her hospitalisation for the second time for the same disease cannot be entertained. She underwent a surgery and was discharged on October 16, 2008. Her doctor found some discharge in the ear and prescribed certain medicines on October 24 and again on November 4.
As it did not heal, he subjected her to second operation on December 19, 2008. The insurance company repudiated the claim citing the condition that post hospitalisation medical charges are covered up to 60 days and in this case the gap between the two surgeries exceeded that limit.
The forum headed by Asha Shetty did not accept this contention and said her treatment did not end on the date of discharge from hospital. It said: “Any … illness (is) deemed to mean continuous period of illness for which treatment is undergone and includes relapse within 45 days from the date of last consultation…” It said the doctor had prescribed medicines on October 24 and also on November 4 for the ailment. “The complainant was continuously under treatment right from the date of admission (October 13, 2008) till she underwent the second surgery.”
The forum asked the company to pay claimed amount and compensation.
