Wednesday, July 28, 2010

Where to lodge your insurance related grievances?

Where to lodge your grievances?

Various options available with any consumer in India are to lodge complain

1. Grievance cell of Insurance Company (after pre empting your phone calls/ visits to their branch, which issued you the policy )
2. Insurance Ombudsman
3. Consumer Forum (at District level, State level and National level)
4. IRDA, which is the new addition.

We welcome the service started by IRDA. But the question before us is why we should have too many authorities for grievance resolutions.

Is it not the responsibility of the Insurance Company to provide service as a part of the product? Why they do not show the name of Grievance Officer, phone no/email on their website. Why they do not have online grievance lodging facility?

The consumers will like to have the data- how many cases lodged against the company in Consumer Forums? How many have been decided? How many have gone in favour of the insurance company and how many have gone against them?

Should there be a fee for lodging a complaint so that incomplete complaints are neither lodged nor received.

Friday, July 23, 2010

Doctors, not insurance cos & TPA’s will judge urgency of cases

Yes there may be time lag of 10 years in coming of the judgment but it is heartening to note that Maharashtra State Consumer disputes Redressal Commission has agreed that it is the doctor ,who has to decide whether it is emergency or not. It is good that this will not be for TPA’s to decide whether it is emergency or not.

It is interesting to note the observations

“An insurance company’s officials are not experts who can decide whether a particular case is of medical emergency or not, the Maharashtra State Consumer disputes Redressal Commission observed while ordering an insurance company to pay Mediclaim to a Versova resident. It is for the expert doctor in the field to give an opinion if this is case of medical emergency or not, the commission stated in its order. The case dated back to 2000. Shamim Khan was working as a schoolteacher in Jeddah, Saudi Arabia. It was during a visit to India in July 2000 that she suffered unbearable stomach pain that led to severe bleeding.

She also experienced breathing problems and her haemoglobin levels began to drop considerably. Khan was admitted to Bombay Hospital immediately where an emergency surgery was conducted. She was discharged after eight days of stay in the hospital and, after incurring a total expenditure of Rs 41,158, Khan lodged a claim for insurance with the New India Assurance Company Limited from whom she had taken a policy. The policy was in force from April 2000 to March 2001.

Kahn’s claim was, however, rejected on the ground that there was no emergency need to undergo the operation” Aggrieved by the repudiation letter she filed a complaint in a district consumer forum, where the insurance company argued that “she (Khan) knew of the illness even before she came to India and had purchased the policy by suppressing material facts of her illness”, son it had the right to repudiated the in surer pleaded.

Khan had, however, procured a doctor’s certificate to the effect that there was an emergency situation and the doctor was required to operate on her to save her life.

Based on this document, the district forum on July 7, 2007, directed the insurance company to pay the medical claim and also Rs 5000 for causing mental harassment to Khan.

The insurance company then filed an appeal against the order in the state commission. But the state commission agreed with the district forum’s view, saying “doctor’s certificate proved beyond doubt that this was clearly a case of medical emergency”.

The commission, while up holding the order of the district forum, added that the insurance company had wrongly repudiated Khan’s claim.

The order- coming at a time when insurance firms are desperately trying to whittle down expenses on claims –will spread cheer among the insured, feel consumers; organizations.

The name of the insurance company was not mentioned in the news which appeared in a leading newspaper .If you know the name of the insurance company then do let us know.

While we respect and appreciate the judgment –it will be better if the fine imposed on such co is higher, because Rs 5000 is a negligible amount for large insurance companies.

Diabetes and BP can’t be cited to reject claim of health insurance claims

Our health insurance providers have used diabetes and hypertension as 2 holy words to reject the claims of insured persons. It is very interesting to read the following news in The Times of India on July 23, 2010

“In another blow to a medical insurer hell-bent on rejecting a policy holder's claims, a district consumer forum has decreed that a cardiac patient cannot be denied his insurance even if he has not mentioned hypertension and diabetes as pre-existing ailments.

"We have taken the view that, in a large number of cases, diseases like hypertension and diabetes are so common and are always controllable... (so) unless a patient undergoes a long treatment, including hospitalization and undergoes operation in the near proximity of taking the policy (sic), (s/he) cannot be accused of concealment of facts," the forum said, while asking the insurer to honour the policy holder's insurance claims and also pay him Rs. 5,000 as compensation for mental agony.

In 2003, Mulund-based Karunakar Shetty underwent a "coronary arteries bypass grafting" surgery and ran up a bill of Rs 2, 53,553. On July 17, 2003, he intimated Oriental Insurance Company Ltd Co and Raksha TPA. Shetty had taken a policy in 2000 for Rs 3 lakh but, while renewing it in 2002 and 2003, the amount was reduced to Rs 1.5 lakh.

In November 2003, Raksha TPA informed him that his claim was rejected as he was suffering from hypertension even before he took the policy and hid this from the insurance company. Shetty, however, contended that he did not suffer from hypertension before he took the policy and even sent a statement from his family doctor to the insurance company. But they did not reconsider their decision, prompting him to file a complaint in the forum citing deficiency in service.

The insurance company denied the allegations and said that in 2003, while renewing the policy, Shetty mentioned that he did not suffer from any pre-existing disease. It even stated that, when the papers were submitted, the third-party authority got documents from a hospital that said Shetty had told them he was suffering from diabetes for the past four years.

The insurance company alleged that the statement submitted by the family doctor was false and argued that the heart ailment that Shetty suffered from was closely related to diabetes and this was not covered by the policy.
The forum, while passing its order took into account, the hospital discharge card that Shetty had submitted following his treatment in July 2002. From the discharge card and the report submitted by the family doctor it was evident that Shetty was suffering from hypertension and diabetes and he got to know of it only in 2002.

The forum observed that Shetty was unaware of the disease when he took the policy in 2000 and, even if he did not mention it in 2003 while renewing the policy, hypertension and diabetes could not be called ‘pre-existing diseases.’

The forum then directed the insurance company and Raksha TPA to jointly or individually pay Rs 1.5 lakh (the insurance amount) with an interest of 6% from November 2003.”

We would have been happier to know the name of the Insurance company .If you know it then do let us know.

Learning from this case is that client was having complete medical file to fight the case and to prove his point to the consumer forum. We have always suggested to you to maintain your medical file.

Diabetes and BP have been the bottleneck in the growth of health insurance .With a view to follow this judgment in the spirit –why not take a liberal view and increase the number of insured by taking these 2 diseases as a way of life for us.

We honour the judgment and with due respect wish to state that 6 % is too low interest to be paid. This should be 12 % which all of us pay. In fact large insurance companies can pay more than this.