Insurance company cannot deny the Mediclaim if duplicate bills are submitted

Consumer Forum news :

healthysoch

New Delhi, February 10, 2019 :

The Mumbai Consumer Forum has recently held that the insurance company cannot reject the Mediclaim on the basis on duplicate bills were submitted. This is a major decision taken and has given relief for all the policy holders.

This order has come due to the application of a Bandra doctor Satyapriya Dhabuwala who was hospitalized in Breach Candy Hospital suffering a brain hemorrhage in 2012. The hospital has charged him with the bill amount of Rs. 1, 71,044 towards hospitalization and other medical expenses.

The original bill were misplaced unfortunately by the complainant and hence he requested the hospital to provide copies of his original bill. The hospital authorities provided him the bills receipt stating they were duplicate copies.

Dhabuwala, submitted the claim of Rs. 1, 71,044 to the insurance company along with all the required documents and bills. The TPA sent him a letter in March 2014 stating to submit the original bills. Dhabuwala immediately replied stating about the misplacement of his original bills and requested to consider the delay in submitting the claim as he suffered cerebral hemorrhage which affected his memory and there was no one else in his family who could have done this.

In April, 2014, the TPA informed him that his claim was rejected as there was a delay of 703 days as per the clause of the policy, Mediclaim has to be claimed within 30 days of discharge of the hospital.

Hence, Dhabuwala had to seek legal action and moved to the South Mumbai District Consumer Disputes Redressal Forum in October 2014. The consumer forum examined the matter and pointed out that the complainant has purchased the policy in 2004 and since then renewing the policy by paying annual premium. The forum also mentioned that the opposite party has failed prove how appropriate duplicate bills are not applicable for filing claims in case the original bills get lost. It also stated that the “Such as act is negligence and deficiency in service and unfair trade practice.”

Also, the district forum has ordered New India Assurance Co Ltd and Health India TPA Services (I) to pay Rs. 2.21 lakh compensation which includes the reimbursement amount along with interest and costs.

BEFORE THE SOUTH MUMBAI DISTRICT CONSUMER DISPUTES

REDRESSAL FORUM,

Puravatha Bhavan, 1st Floor, General Nagesh Marg, Near Mahatma Gandhi

Hospital, Opp. M.D. College, Parel, Mumbai – 400 012.

O.No.

Complaint No. : SMF/MUM/ CC/2014/228
Date of filing : 16/10/2014
Date of Order: 25/01/2019

Dr. Satyapriya Dhabuwala,
R/at 7/63, Sona, MHB Colony,
Bandra Reclamation,
Mumbai – 400 050. … COMPLAINANT
V/s.
1. The New India Assurance Co. Ltd.,
Registered Office at : 87, M.G. Road,
Fort, Mumbai – 400 001.
Regional Office at : 1, New India Bhavan,
2nd Floor, 34/38, Bank Street, Fort,
Mumbai – 400 023.
2. Health India TPA Services (I) Ltd.,
Anand Commercial Co. Compound,
Gandhi Nagar, Vikhroli (West),
Mumbai – 400 083. …Opposite Party / Opponent Nos. 1 &2
Coram:

Smt. Sneha S. Mhatre : Hon’ble President
Shri. D.S. Paradkar : Hon’ble Member
Shri. M.P. Kasar : Hon’ble Member

Source: https://business.medicaldialogues.in/mediclaim-cannot-be-rejected-if-duplicate-bills-are-submitted-consumer-forum-on-doctors-plea/