Consumer forum directs insurance company, TPA to pay Rs 3.43 lakh to man who underwent COVID-19 treatment in 2020

A consumer forum in Thane has directed an insurance company and a third party administrator (TPA) to pay a man Rs 3.43 lakh, which includes the balance amount of his claim and compensation towards mental agony, in connection with his COVID-19 treatment at a hospital in 2020.

Thane District Consumer Disputes Redressal Forum President V C Premchandani and member Poonam V Maharshi in the order also said the complainant has succeeded to prove that the opponents – the insurer and the TPA – have adopted unfair trade practice towards him by sanctioning the claim amount up to Rs 1,34,000, as against the total hospital bill of Rs 4,47,771.

The order was passed on April 6 and a copy of it was made available on Monday.

The complainant told the forum that he was admitted to a hospital in Kalyan town of Maharashtra’s Thane district for treatment of COVID-19 from July 1 to 12, 2020.

His hospital bill was Rs 4,47,771 and he lodged a claim for the same with the insurance company which sanctioned only Rs 1,34,000 and paid it.

The complainant objected to it and made various communications with the opponents, but they failed to settle the balance claim amount.

The complainant prayed to the forum that the opponents be directed to pay the balance hospital claim amount of Rs 3,13,771 and also compensation for his mental harassment and litigation expenses.

The complainant had obtained the mediclaim insurance policy for the period from February 2020 to February 2021 and the sum assured was Rs 5,25,000.

The forum said though a notice was issued to the opponents, they failed to appear to place their defence on record and to prove that why only a sum of Rs 1,34,000 towards the claim amount was sanctioned.

As the policy sum assured was Rs 5,25,000, the complainant was entitled to have the total claim amount. The complainant has also submitted that along with the policy, no terms and conditions have been provided to him, it said.

Hence, the forum directed the two opponents to pay the balance claim amount of Rs 3,13,771 along with an interest at 10 per cent per annum till the realisation of the amount.

It also directed the opponents to pay to the complainant a compensation of Rs 20,000 for mental agony and harassment and Rs 10,000 as to cost of the proceeding.

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