Commission directs insurance company to reimburse medical claim of customer

COIMBATORE: The district consumer disputes redressal commission has directed a private insurance company to reimburse a medical claim of Rs 10.25 lakh to a customer along with Rs 10,000 as compensation for mental agony and deficiency in service. In its order, the commission comprising president R Thangavel and member P Marimuthu also directed the insurance company to pay the customer Rs 5,000 towards the cost of the proceedings.

According to official sources, V Sureshkumar of Besant Nagar in Chennai obtained a medical insurance policy from Niva Bupa Insurance for his mother, with a coverage of Rs 1.12 crore, by paying a premium of Rs 2.31 lakh. His mother underwent a surgery to remove metal plates that were inserted in her leg following a fracture. She was admitted to a private hospital in Coimbatore on March 13, 2024.

As the hospital did not have a cashless tie-up with the insurance company, Sureshkumar paid the expenses for the surgery and hospitalisation himself. His mother was discharged on March 16, but the following day she was unable to speak properly and was readmitted to the same hospital. She was diagnosed with a brain stroke and admitted to the ICU.

Since the hospital did not have an advanced CT scan facility for detailed brain imaging, she was shifted to another private hospital. The insurance company advised Sureshkumar to bear the expenses and claim reimbursement later. While he was arranging funds and focusing on his mother’s treatment, she died on April 3.

Sureshkumar submitted all hospitalisation-related documents to the insurance company, but his claim was rejected. He subsequently filed a petition before the Coimbatore district consumer disputes redressal commission, seeking direction to settle his claim of Rs 10.25 lakh. The commission ruled in his favour.