Belagavi District Commission Holds Oriental Insurance Company Liable For Wrongful Repudiation Of Genuine Medical Claim

Brief Facts:

The Complainant held a Mediclaim insurance policy with Oriental Insurance Co. Ltd. (“Insurance Company”) for several years. While this policy was active, the Complainant tested positive for COVID-19 and was treated at KLE's Hospital Belagavi followed by regular follow-up treatment after discharge. The hospital charged him Rs. 1,40,391/-, and he incurred an additional Rs. 30,000/- towards medicines and other expenses. The Complainant sought reimbursement for these expenses from the insurance company, submitting all relevant medical records and bills, but the insurance company didn't make the payment despite retaining the documents.

The Complainant's wife, who was also infected with COVID-19, had her entire medical expenses reimbursed by the insurance company. However, for reasons unknown, the insurance company did not reimburse the Complainant's medical expenses. Feeling aggrieved, the Complainant filed a consumer complaint in the District Consumer Disputes Redressal Commission, Belagavi, Karnataka (“District Commission”) against the insurance company. The insurance company didn't appear before the District Commission.

Observations by the District Commission:

The District Commission referred to the insurance policy, the discharge summary, the inpatient final bill, and receipts. It noted that the Complainant had valid insurance coverage during his hospitalization for COVID-19 treatment. Further, the Complainant was diagnosed with COVID-19 and had undergone treatment, but the insurance company failed to reimburse the hospital bills. The District Commission held the insurance company liable for deficiency in service.

Consequently, the District Commission directed the insurance company to pay the insured amount of Rs. 1,50,000/- to the Complainant with 6% interest per annum. Additionally, the District Commission directed the insurance company to pay a compensation of Rs. 5,000/- to the Complainant for mental agony and Rs. 2,000/- for litigation expenses.

Case Title: Sangamnath Murgeppa Kardeguddi vs The Oriental Insurance Co. Ltd.

Case Number: Complaint No. 46/2024

Date of Pronouncement: 17.05.2024

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