The company has to pay Rs. 50,000 being the value of the policy
Complainant had bought the policy in January last
Company fails to substantiate its stand on surgery
MANGALORE: The Dakshina Kannada District Consumer Disputes Rederessal Forum has directed the New India Assurance Company Ltd. to honour the medical claim of a policy-holder in full. The company had offered to honour a part of the bill.
The company has been asked to pay Rs. 50,000 to the policy-holder, who underwent a surgery at a private hospital here in April last year, and incurred an expense of Rs. 65,181.
The policy-holder, Ramayya Bangera of Surthkal, had taken a policy of Rs. 50,000, valid for one year from January 21, 2008.
The surgery he underwent was termed as “PCNL for impacted calculus at the PU junction causing infected hydronephrosis”.
The insurance company described it as an operation for removal of kidney stone and said that Mr. Bangera was eligible to get Rs. 13,500 as he had bought a “Janata” policy under a Central Government’s health scheme.
Mr. Bangera contended that the stand taken by the insurance company was incorrect and that he was entitled to receive the full value of the policy of Rs. 50,000. When the company did not comply with it, he complained to the forum stating that it amounted to deficiency in service.
Before the forum, the company argued that Mr. Bangera was eligible to receive reimbursement of only certain charges under the scheme and there was no deficiency in its service, and prayed for dismissal of the complaint.
Lack of evidence
The forum said the company had not furnished any document to show that the surgery that Mr. Bangera underwent was nothing but removal of kidney stone. “The company ought to have … shown (that) it is a case of kidney stone but no such evidence was produced before the Fora (Forum).”
The forum declined to consider the defence taken by the company and directed it to pay Rs. 50,000, along with eight per cent interest, and Rs. 1,000 towards cost of litigation, within one month of the date of judgement.
Somanath Rao, senior branch manager at the local office of the company, told The Hindu that the forum’s decision would be certainly honoured.