Group Mediclaim Policy - Gbic.co.in

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Hyderabad Ombudsman CentreCase No. IO (HYD) / G.11.002.007Ms. H. R. JayasimhaVsThe New India Assurance Co. Ltd.Award Dated 30.5.2005The complainant, a retired employee of LIC of India was a member of the GroupMediclaim policy issued by the above insurer.He underwent laser treatment for both eyes at Narayana Netralaya on 29.12.2004 andsubmitted a claim bill for Rs. 2,150/- towards reimbursement of hospitalizationexpenses. The insurers rejected the claim, vide their letter dated 8.2.2005, on thegrounds that the insured - member submitted case summary as against dischargesummary and that the treatment taken by the complainant was not as in - patient asenvisaged in the preamble of the mediclaim policy issued to him.It was held that the case summary submitted by the insured clearly states that he wasin hospital from 1.30 p.m. to 3.00 p.m. on 29.12.2004. The data regarding admissiontime and discharge time can be culled out from the summary. Insistence of a separatedischarge summary just to satisfy the claim settlement formalities is absurd.Hyderabad Ombudsman CentreCase No. IO (HYD) / G.11.002.028Shri T. S. VenugopalVsThe New India Assurance Co. Ltd.Award Dated 1.6.2005The complainant was covered under the group mediclaim policy under Can ComfortScheme specially devised for Canara Bank Credit Holders. The first policy was takenfor the year 1993 - 94 with M/s. National Insurance Co. Ltd., The policy was latershifted to New India Assurance Co. Ltd. with effect from 1.1.1996 and was continuouslyrenewed in chain without a break.The complainant underwent angiogram and subsequently a coronary artery by - passgraft surgery in March, 1997 and the insurance company reimbursed an amount of Rs.50,000/- to the complainant towards hospitalisation expenses.In 2004, he complained of chest pain and underwent Angiograme / Angioplasty. Hepreferred claim for Rs. 1,74,416/- with the insurers towards reimbursement ofhospitalisation expenses.M/s Medi Assist, the Third Party Administrators (TPA) of the insurer, vide their letterdated 20.9.2004, approved the claim for Rs. 28,539/- as against his original claim billof Rs. 1,74,416/-. The claim was settled in accordance with Can Comfort PolicyExclusion No. 415. This clause states “the policy being continuously in force and ifincreased benefits (higher benefit plan) are availed through the policy in force, theincreased benefits are not applicable for those illness, diseases contracted / sufferedduring the previous policy period. The claim for the said illness / disease / disability ifadmitted shall be processed as per previous year’s policy limits only”.It was held that the complainant was covered undr the scheme since 1996 and thepolicy issued to him without this clause 4.15. This condition was made known to himonly in the year 2003. Charges in the scheme into which clause 4.15 was inducted wasnot informed to the policy holder. Hence, complainants claim for reimbursement should
e considered as per the terms and conditions of the policy without invoking clause4.15.Hyderabad Ombudsman CentreCase No. IO (HYD) / G.11.002.012Shri Batti Shankar GoudVsThe New India Assurance Co. Ltd.Award Dated 13.6.2005Complainant, an LIC employee, was covered under the group mediclaim policy with therespondent company for the period 1.4.2004 to 31.3.2005.He was diagnosed to have enteric fever and was hospitalised on 1.4.2004 anddischarged on 3.4.2004. He preferred a claim for Rs. 3,664/- The insurer processed theclaim for Rs. 2,165/- and rejected an amount of Rs. 1,499/- on account of excessmedicines purchased by him.The complainant contended that the bill of Rs. 3,664/- was paid by him towardsmedicines and hospitalisation expenses as prescribed by the doctor / hospital.Held : Insurers have been liberals and calculated claim for 3 days as against theinvestigator’s observations. Complainant has not furnished the case sheet despiteinsurer’s request for the same. The respondent company has been more thanreasonable in allowing the claim. The complainant cannot be adamant in his stand ofnot furnishing required documents. With the papers available in the file. I believe thatthe insurer was fair in his calculation The insurers are directed to process and pay theclaim for Rs. 2,165/- as calculated. Complainant’s request for consideration of fullamount is not justified.Hyderabad Ombudsman CentreCase No. IO (HYD) / G.11.004.045Smt. Darsi Kanaka DurgaVsM/s. United India Insurance Co. Ltd.Award Dated 19.7.2005Shri Darsi Himachala Rao an employee of United India Insurance Co. Ltd. was coveredunder Staff Ground Mediclaim Scheme since 1984. He also covered his parents sincethen and allowed requisite premium to be deducted from his salary. He had also put upclaims on earlier occasions and these claims were honoured. In the current case, theinsurer was intimated even before Smt. Kanaka Durga was admitted into the hospital.Immediately, after the treatment, the necessary claim papers were submitted in July,2003. However, the claim is not settled but once he was offered a partial payment ofRs. 90,000/- on 23.11.2004 without assigning any reasons for reducing the claimamount from Rs. 1,62,000/-. Complainant refused to accept the same.The insurer contends that as an employee of the insurance co. he is expected to beaware of rules & regulations of the organisation and moreover he had wrongly includedhis father and mother as dependants, though rules clearly do not allow the inclusion ofparents if any of the parent is drawing a pension of more than Rs. 1,500/- per month.Held : In my view, making payment of some earlier claims cannot be taken as excusefor making wrongful claim once again. During the hearing, the respresentative of theinsurer was asked to give the reasons for making an offer of partial payment. The
Page 4 and 5: was held that the insurer could not
Page 6 and 7: In the facts and circumstances of t
Page 8 and 9: insured under the maternity benefit
Page 12: employee should have appreciated th

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