Finding the medical opinion of a doctor that “falling in the bathroom has no link with arthritis”, the District Consumer Disputes Redressal Commission of Chandigarh has directed an insurance company to settle a claim of Rs 1,75,775, of a Chandigarh-based woman, whose claim for fracture was rejected by the insurance company.
Subhash Chander Khanna and his wife, Urmil Khanna, took a medi-claim policy from the The Oriental Insurance Company Limited. The complainant got himself and his wife (complainant No.2) insured for a sum of Rs 5 lakh towards the medical expense under the policy. As per the complaint, on April 5, 2019, Urmila slipped and fell in the bathroom. She had pain killer for three-four days and when the pain did not go, she went for medical tests and it was diagnosed that there is fracture in the knee. Doctors at Apollo clinic advised to conduct surgery on the knee and assured that after recovery, she will be able to walk normally. The surgery was performed at Chandigarh City Hospital, Sector 8.
As per complaint, the complainants preferred the mediclaim from the insurance company and submitted the claim under two bills amounting Rs 11,592 and Rs 1,49,067, and two more bills which is of Rs 8,196 and Rs 6,920 spent towards the treatment at Apollo clinic and spent towards Omni Clinic and Diagnostic.
The complainants kept on approaching the insurance company for settlement of claim but no heed was paid to repeated requests and visits by the complainants.
The Oriental Insurance Company Limited in reply submitted that as per the terms and conditions of the insurance policy, the present claim is not payable because as per the treatment record, the insured patient is a known case of hypertension since seven years and arthritis since four years and as per the insurance policy, pre-existing disease/injury/health condition are excluded uptill three years from the date of inception of policy.
Further, terms and conditions of the insurance policy specifically talks about situation in case of the pre-existing disease.
The commission after hearing the matter, went through the medical opinion of a doctor, as per which “the said injury received due to fall in bathroom is not related to the arthritis.”
Thus holding that rejection of the claim by the insurance firm is not justified, the commission directed the insurance company to settle and pay the claim of Rs 1,75,775 to the complainants, and Rs 25,000 as compensation and Rs 10,000 as cost of litigation.