The Consumer Disputes Redressal Forum, Ahmedabad (Rural), held the Oriental Insurance Co. Ltd. guilty of deficiency in service on 21 September 2010 and directed it to pay Rs. 46,000 with 9 per cent compound interest to Sarojini Khemka from the date of the complaint till payment. It also directed the company to pay Rs. 5,000 as compensation for her mental agony and harassment and the cost of litigation.Â
Earlier, on the basis of Sarojini’s complaint to Consumer Education and Research Society (CERS), Ahmedabad, they had jointly approached the Forum, with CERS as the first complainant.
Sarojini’s husband, the late Ram Nandalal Khemka, had taken a healthcare policy from Oriental Insurance and renewed it in time. During the term of the policy, he had to be admitted to Lifeline Nursing Home on 17 June 2005 on medical advice as he had been suffering from constant high grade fever. Blood tests did not indicate the nature of the fever. Three days later, while in hospital, he developed an acute pain in the abdomen and had a CT scan done at the Hi Tech Diagnostic Centre of the nursing home. It showed a mild intestinal obstruction. After medication, he was discharged on 30 June.
Meanwhile, soon after her husband’s admission to the hospital, Sarojini had submitted the form for “cashless service†to Oriental Insurance’s local agents at Ahmedabad, Paramount Health Services Ltd. (PHSL). Though the insurer and its agent had given him an ID number, they refused the cashless service. Their “Denial of Cashless Access†statement of 20 June mentions,
“From the available medical data, we are unable to arrive at policy coverage and hence cashless services cannot be provided.†The statement did not explain the refusal of this service except that it attributed his abdominal pain to a 20-year-old intestinal disease for which he had undergone an appendectomy.Â
The claim papers demanded Rs. 46,000 but the opposite parties refused the claim on flimsy and untenable grounds. CERS received a letter dated 13 September 2006 from Sarojini, saying her husband had expired a week earlier.
CERS issued a legal notice on 19 October 2006 and received replies from the opposite parties, repudiating the claim. CERS and Sarojini, as mentioned, complained to the Forum.
The Forum observed in its order, four years after the death of Ram Nandalal, that the complainants had succeeded in establishing their case in which Sarojini had incurred Rs. 46,000 on her husband’s treatment and medicine. The opposite parties had rejected the family’s mediclaim without any valid reasons. All that they had cited was a 20-year-old disease which, in the Forum’s view, was not valid as the company had noted.
The Forum clarified that the opposite parties had not produced any documentary evidence on how the abdominal pain suffered by the deceased was related to the 20-year-old disease, i.e. intestinal pain, diagnosis of appendicitis and the subsequent appendectomy. By denying the mediclaim to the complainant, the opposite parties had committed negligence and deficiency in service. The Forum allowed the complaint.
