Indore (Madhya Pradesh): The Akhil BharatiyaGrahak Panchayat (ABGP) on Wednesday helped a policyholder, Suresh Kumar Jain, secure his health insurance claim after it was rejected by the Oriental Insurance Company.
Jain, who bought the Happy Family Floater Medical policy on August 14, 2013, experienced sudden chest pain and was admitted to the Vishesh Hospital in Indoreon July 7, 2017, where a stent was implanted in his heart. The Oriental Insurance Company denied his claim, citing Clause 4.1 of the policy, which restricts coverage for pre-existing diseases within the first four years, and the claim was days short of the period.
Challenging this denial, the Grahak Panchayat filed a case on Jain’s behalf in the Indore District Consumer Commission. ABGP’s Manoj Pawar said the insurance company rejected the claim because Jain’s condition was linked to pre-existing diseases such as obesity, hypertension, and diabetes, which, according to the policy, were only covered after four years.
However, they argued that such conditions are now a common part of everyday life, and outright denying the claim based on a policy clause amounted to a deficiency in service, said Pawar.
The Consumer Commission ruled in favour of Jain, ordering Oriental Insurance to pay the claim amount of ₹2,49,581 within 45 days from the date of filing of the complaint, with 6% interest on the amount.
Additionally, the company has to pay ₹5,000 as compensation for mental agony and ₹5,000 towards litigation expenses.
