"Your readers may be advised to approach the District Consumer Forum in case of rejection as nowadays insurance companies are known to reject claims on frivolous grounds…. The case in the Consumer Forum is settled within a short time unlike courts,” stated Hyderabad based reader and managing committee member of the Parsi Zoroastrian Anjuman of Secunderabad and Hyderabad, Kerfegar Antia who shared the outcome of a battle with his medical insurers with Parsiana.
On November 15, 2021, his wife Farida suddenly complained of uneasiness and blurred vision. Kerfegar rushed her to Kamineni Hospital where they admitted her in the emergency room and found her blood pressure had shot up which could have led to a stroke. "They undertook a series of tests at midnight and admitted her for treatment and observation. She was finally discharged on November 17, after paying Rs 34,470 towards hospitalization and medical expenses.”
The claim was promptly submitted to the insurer, National Insurance Company Limited (NICL), on November 25. "However, the insurance company rejected my claim on the frivolous ground that the claim pertains to evaluation purpose… After my appeals were rejected by their third party administrator, I filed a case in the District Consumer Disputes Redressal Commission, Hyderabad.”
Quoting Supreme Court judgments, the suit was decreed in favor of the Antias with the remark, "Laboratory/diagnostic tests, X-ray, CT Scan, MRI, any other scan and similar such expenses that are medically necessary or incurred during hospitalization as per advice of an attending doctor are covered under the policy.” The insurer was directed to pay Rs 34,470 plus Rs 20,000 towards compensation for mental agony, within 45 days from date of receipt of order failing which interest at nine percent would be levied from date of receipt of order till actual payment. The suit was decided within six months.
Meanwhile, in another case, the Baroda Consumer Forum has held that a claim is valid even if the insured has been hospitalized for less than 24 hours. NICL was ordered to pay for the hospitalization expenses of the wife of one Rameshchandra Joshi, the claim amount of Rs 44,468 plus interest from the date the insured’s claim was rejected, and compensation of Rs 3,000 for mental harassment. The Times of India of March 15, 2023 noted that the Forum observed that "Even if it is assumed that the patient was admitted for less than 24 hours, in the modern age, new treatments and medicines have been developed and the doctor gives treatment as per that.”
Set up under the Consumer Protection Act of 1986, redressal forums exist at the district, state and national levels. Their website http://ncdrc.nic.in/ provides district-wise contact details.