The apex consumer court in Maharashtra has shown insurance firms their place, directing that it is the doctor — and not the insurer — who
can decide whether a case requires emergency medical attention or not. It has also fined the insurer Rs 5,000 for rejecting a claim on this ground lodged by a Versova resident.
The order — coming at a time when insurance firms are desperately trying to whittle down expenses on claims — will spread cheer among the insured, feel consumers’ organizations.
“An insurance company’s officials are not experts who can decide whether a particular case is of medical emergency or not,” the Maharashtra State Consumer Disputes Redressal Commission observed while ordering an insurance company to pay mediclaim to a Versova resident. “It is for the expert doctor in the field to give an opinion if this is a case of medical emergency or not,” the commission stated in its order.
The case dates back to 2000. Shamim Khan was working as a schoolteacher in Jeddah, Saudi Arabia. It was during a visit to India in July 2000 that she suffered unbearable stomach pain that led to severe bleeding.
She also experienced breathing problems and her haemoglobin levels began to drop considerably. Khan was admitted to Bombay Hospital immediately where an emergency surgery was conducted. She was discharged after eight days of stay in the hospital and, after incurring a total expenditure of Rs 41,158, Khan lodged a claim for insurance with the New India Assurance Company Limited from whom she had taken a policy. The policy was in force from April 2000 to March 2001.
Khan’s claim was, however, rejected on the ground that there was “no emergency need to undergo the operation”. Aggrieved by the the repudiation letter she filed a complaint in a district consumer forum, where the insurance company argued that “she (Khan) knew of the illness even before she came to India and had purchased the policy by suppressing material facts of her illness”; so it had the right to repudiate the claim, the insurer pleaded.
Khan had, however, procured a doctor’s certificate to the effect that there was an emergency situation and the doctor was required to operate on her to save her life.
Based on this document, the district forum on July 7, 2007, directed the insurance company to pay the medical claim and also Rs 5000 for causing mental harassment to Khan.
source: Economic Times