Delhi State Commission: Insurance Company Cannot Indefinitely Delay Genuine Mediclaim Settlement On Mere Suspicion Without Evidence

The Delhi State Consumer Disputes Redressal Commission comprising Justice Sangita Dhingra Sehgal (President) and Pinki (Member Judicial) has dismissed an appeal filed by United India Insurance Co. Ltd., affirming that an insurer cannot indefinitely delay or deny legitimate medical reimbursement claims based on unsubstantiated allegations of non-cooperation.The Commission held that in the absence of any investigation report, evidence of fraud, policy exclusion, or proof of fabricated treatment records, the insurer's failure to settle the claim amounted to deficiency in service.Brief Facts The complainant, Gurvinder Singh Bhasin, had obtained a mediclaim policy from United India Insurance Co. Ltd. for the period from June 13, 2013 to June 12, 2014. During the currency of the policy, his son Bavjyot Bhasin was admitted to Ekansh Nursing Home from October 12, 2013 to October 17, 2013. Intimation regarding hospitalization was furnished to the insurer's TPA on October 13, 2013. The complainant incurred medical expenses amounting to ₹38,195 and submitted a reimbursement claim along with treatment records and claim documentsHowever, the insurance company did not settle the claim. Aggrieved, the complainant approached the District Consumer Disputes Redressal Commission alleging deficiency in service. The District Commission allowed the complaint and directed the insurer to reimburse ₹38,195. Challenging the order dated January 23, 2016, United India Insurance Co. Ltd. filed an appeal before the Delhi State Consumer Disputes Redressal Commission.Contentions of the Insurance companyThe insurer contended that the claim could not be processed because certain queries raised by the TPA, including leave records and clarification regarding investigations conducted during hospitalization, were allegedly not satisfactorily answered by the complainant. It further argued that the complainant had failed to furnish the requisite documents necessary for processing the reimbursement claim and that the complaint itself was premature since the matter was still under consideration before the TPA and underwriting office.Observations and Decision The Commission observed that despite receipt of hospitalization intimation and claim documents, the insurance company failed to take any final decision on the reimbursement claim within a reasonable period. The Commission noted that the insurer had merely made bald allegations regarding pending queries and incomplete documents without producing any convincing documentary evidence to show that the complainant had deliberately withheld information or failed to cooperate in the claim process. The Commission further held that the insurance company had failed to place on record any exclusion clause, investigation report, medical opinion, or evidence showing that the hospitalization or treatment was fictitious, manipulated, or outside the scope of the policy. It observed that once the insured had submitted the available treatment records and authorized the TPA to obtain documents from the hospital, any further verification was the responsibility of the insurer and its TPA. Holding that the non-settlement of the reimbursement claim of ₹38,195 without any valid or proven ground amounted to deficiency in service, the Commission found no infirmity in the District Forum's order directing payment of the mediclaim amount. Accordingly, the appeal filed by United India Insurance Co. Ltd. was dismissed and the order directing payment of ₹38,195 to the complainant was upheld. Case Title: United India Insurance Co. Ltd. v. Gurvinder Singh Bhasin & Ors.Case No.: FA-255/2016Click Here To Read/Download Order

Delhi State Commission: Insurance Company Cannot Indefinitely Delay Genuine Mediclaim Settlement On Mere Suspicion Without Evidence

Praveen Mishra

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Delhi State Commission: Insurance Company Cannot Indefinitely Delay Genuine Mediclaim Settlement On Mere Suspicion Without Evidence

Praveen Mishra

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