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Press Note Consumer forum: Late submission of claim file (Mediclaim) is not a legal ground to repudiate the claim.

-------------------------------------------------------------------------------------------------------------------In the instant case the Complainant was a senior citizen and was covered under the Mediclaim Policy since last 6 years and was admitted in the Hospital and was operated for Hernia and the intimation was given to the TPA by the complainants personally. The claim file was submitted by the complainant to the agent of the insurance company, Thereafter, the agent went to the USA and asked the client-complainant to contact the other agent engaged by him in his absence. Accordingly the client-complainant handed over the file to the aforesaid engaged agent. After a considerable time, on asking about the status of claim, the aforesaid engaged agent replied that he has submitted the claim file and it takes three to four months for the claim to be processed. And thereafter the said engaged agent told that the insurance company is asking for the fitness certificate and therefore the clientcomplainants obtained the fitness certificate and submitted it a little late. Then after a long time, the said agent informed the client/complainant that the insurance company is not accepting the claim file since the file is delayed and returned the file to the client/complainants. The complainant then himself with the help of some other agent tried to file the claim but all his efforts went in vain as the TPA did not accept the same. Therefore, the complainant met with Divisional Manager of the insurance company and gave the clarifications about delay; and Divisional Manager of the insurance company issued a letter asking the TPA to process the claim stating that the reasons for delay given by the complainant, were genuine and therefore the TPA should process the claim on the merits but TPA did not condone the delay and repudiated the claim. The complainant thereafter filed complaint before the Insurance Ombudsman and the same was disallowed by the award of the insurance ombudsman. The claim of the complainant was genuine and was for the period of the hospitalization which was not in dispute. There was a considerable delay caused in putting up the claim file by the Complainant as he was a senior citizen and also not able to manage the things and the agent of the insurance company due to other assignees of the work also not able to manage the things on desirable time, complainant also made written and oral representations to various authorities of the insurance company and Divisional Manager of the insurance
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company issued a letter asking the TPA to process the claim and stated that the reasons for delay that were given by the complainant were genuine and the TPA should process the claim on the merits but even after that the TPA did not condone the delay and repudiated the claim. The reason for the delay has been explained and same is known to the insurance company and the insurance companys officer has appreciated the reasons for the delay. Complainant filed complaint before the Honble Consumer Forum and forum considered that the claim cannot be repudiated when the claim is genuine merely on the ground of delay in putting the claim file in to the company, which is well explained. The insurance company is in the dominant position and should not be allowed to misuse its powers in that position and cause the prejudice to the consumers. In some companies, the intimation clause of 24 hours, by hand delivery, is otherwise also unreasonable as the same is not possible certain times, in the cases where the claimants are facing the troubles of hospital and treatment, that such conditions should not be allowed to be used for repudiation of the policy. The insurance ombudsman was also primarily dealt on the issue of the repudiation as per the condition but the ombudsman has not gone into the facts of the case and circumstances of delay and the same was appreciated by Honble consumer forum. If the officers of the insurance company had found the reasons of the complainant to be justified then the TPA was duty bound to reconsider the claim. Insured senior citizen saluted Honble Consumer Disputes Redressal Forum for justice and award. Basically, as the mediclaim policy is covering 60 to 90 days of post hospitalization expenses, therefore the insured was allowed to put the claim file after 10-15 days of completion of post hospitalization expenses period, and there after the company will require 2/3 months to process the whole claim file and the whole procedure of claim from the day of hospitalization was taking too much longer time to disburse the claim amount to the insured. Now, in the interest of the insured and company and to disburse the claim amount as early as possible and even for the taxation purpose and to give early and actual effect to the profit & loss accounts and balance sheet of the insurance company, the drafters of the policy may tried to manage/replace that clause of filing claim within 10-15 days after discharge from the hospital. However, then question was raised what about the expenses of post hospitalization of 60-90 days claim bills, and the drafter came up with the solution of putting/submitting another file of post hospitalization expenses again after 10-15 days of completion of the post hospitalization treatment, since, the post hospitalization expenses are nearly 5% to 15% of total claim amount, which will help to minimize the amount to be carried forward to the next year and the pending work will be less.
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Now see the very good and bonafide intention of the policy makers/drafters and see the interpretation of the other officers implementing the policy decision/condition, they started rejecting the claims on the ground of not submitting the claim file within 10-15 days after discharge from the hospital and not intimating within 24 hours in person only. Which means one must leave the patient to die and go to the insurance company to give the intimation, that too not through fax or email but personally. Intimation within 24 hours should not be interpreted literally as within actual 24 hours, but as soon as possible so that the insurance company can get a chance to investigate the matter to avoid the frauds / cheatings. If for any reason, someone is not able to intimate the insurance company within 24 hours, then also after 24 hours the investigator can visit the patient in hospital and after that at his home and can always verify the indoor case papers of the hospital. Intimation not within stipulated time and delay in submission of claim file must not be the grounds for the refusal of claims. We salute our judiciary for boosting our confidence further by acting dynamically and bringing various rights under the scope of Fundamental Rights, we also extend our heartiest thanks to our Legislators for enacting the acts like Right to Information Act and making the mechanism effective to some extent. By:

manohar makhija

(advocate & Inquiry Officer) (Panel No.4, Registrar of Co-Operative Societies , Gujarat State-Gandhinagar) Office No. 14, Grd Flr, Sarthak Towers, Nr. Ramdevnagar Cross Rd, Satellite, Ahmedabad-15 (M) +91 094264 06046, E-mail: manohar.makhija @ yahoo.co.in