Business Medical Dialogues
    • facebook
    • twitter
    Login Register
    • facebook
    • twitter
    Login Register
    • Medical Dialogues
    • Speciality Dialogues
    • Education Dialogues
    • Medical Jobs
    • Medical Matrimony
    • MD Brand Connect
    Business Medical Dialogues
    • News
        • Financial Results
        • Hospitals & Diagnostics
        • IT / Health Venture
        • Implants / Devices
        • Insurance
        • Key Movement
        • Pharmaceuticals
        • Policy
        • Technology
        • pharma-news
    • blog
    LoginRegister
    Business Medical Dialogues
    LoginRegister
    • Home
    • News
      • Financial Results
      • Hospitals & Diagnostics
      • IT / Health Venture
      • Implants / Devices
      • Insurance
      • Key Movement
      • Pharmaceuticals
      • Policy
      • Technology
      • pharma-news
    • blog
    • Home
    • Editors Pick
    • Mediclaim cannot be...

    Mediclaim cannot be rejected if duplicate bills are submitted: Consumer Forum on doctors plea

    Meghna A SinghaniaWritten by Meghna A Singhania Published On 2019-02-08T17:18:19+05:30  |  Updated On 13 Aug 2021 2:43 PM IST

    MUMBAI: In a major relief to policyholders, the Mumbai Consumer Forum has recently held that in case of loss of original hospital papers and bills in a medical claim, the insurance company cannot deny the claim on the grounds that duplicate bills were submitted.


    The order came following the application of a Bandra doctor, Satyapriya Dhabuwala, who was admitted to the Breach Candy Hospital as he was suffering from a brain haemorrhage in 2012. He was hospitalized between February 8 and 19, 2012. The hospital discharged him on 19.2.12 with bills amounting to Rs 1,71,044 towards hospitalization and other medical expenses incurred.


    Unfortunately, the original bill receipts given by the hospital were misplaced by the complainant and therefore he requested the hospital to furnish him copies of cash bill receipts. On the said request the hospital authorities furnished him the duplicate cash bill receipts endorsing that they were duplicate.


    Thereafter, the complainant submitted a claim of Rs 1,71,044 to the India Assurance Co Lt (Opposite Party 1) and Health India TPA Services (I) Ltd.(Opposite Party 2) with all required and relevant documents.


    However, the TPA sent him a letter in March 2014 and informed him that he had to provide the original bill with the detailed break-up and original cash bill receipts.


    Following the same, Dhabuwala immediately wrote to them with details about misplacing original bills and also urged them to consider the delay due to the cerebral haemorrhage he had suffered which had affected his memory and mental faculties. Further, he stated that there was no one else in the family who could have submitted the claim.


    To Dhabuwala's dismay, in April 2014, the TPA informed him that the claim was rejected as there was a delay of 703 days. The company "rejected condensation approval due to inordinate delay and as per clause 11.0 of mediclaim policy the present claim was repudiated."



    Clause No.11.0 of Medi claim policy states that –
    'Clause 11.0 : Final claim along with Hospital receipted original Bills/Cash Memos ,claim form and documents as listed in the claim form should be submitted to the policy issuing office/TPA not later than 30 days of discharge from the Hospital. The insured may also be required to give the company/TPA such additional information and assistant as the -company/TPA may require in dealing with the claim from time to time.

    At the same time, the insurance company denied the claim alleging that the complainant has consciously suppressed material facts and he has not come to the court with clean hands. "He even does not disclose any cause of action & mentioned the cause of action is not maintainable & same ought to be dismissed with costs," the company told the court. The company further stated that the complainant was well aware of the terms and conditions of the policy and which he did not abide by while submitting his claim.


    The complainant then sought legal intervention and moved the South Mumbai District Consumer Disputes Redressal Forum in October 2014.


    The consumer forum after examining the matter pointed out that Dhabuwala had been purchasing the insurance policy since 2004 and also renewing it by paying the annual premium.


    "It also appears duplicate bills have been produced by the complainant to the insurer as originals were lost by him. Opposite party (insurance company) has failed to prove how appropriate duplicate bills are not applicable for filing the claim in case originals get lost," the forum said.


    The forum further stated that it was evident the insurance company had not considered the claim reasonably. "Such an act is negligence and deficiency in service and unfair trade practice," the forum added.


    Subsequently, the district forum has ordered New India Assurance Co Lt and Health India TPA Services (I) Ltd, to pay Rs 2.21 lakh compensation wherein the reimbursement amount is of Rs 1.71 lakh and rest as interest and costs.


    Also Read: Medical Insurance Co will have to pay interest for mediclaim payout delay: Maharashtra Consumer Forum

    bandra doctorbest medical insuranceconsumer forum latestdoctor mediclaimduplicate medical billsfamily medical insuranceHealth India TPA ServicesMaharashtra Forummedical insurancemedical insurance Indiamedical insurance plansMumbai Consumer ForumNew India Assurance Co Ltpremium medical insurance policy

    Disclaimer: This site is primarily intended for healthcare professionals. Any content/information on this website does not replace the advice of medical and/or health professionals and should not be construed as medical/diagnostic advice/endorsement or prescription. Use of this site is subject to our terms of use, privacy policy, advertisement policy. © 2020 Minerva Medical Treatment Pvt Ltd

    Meghna A Singhania
    Meghna A Singhania

      Meghna A Singhania is the founder and Editor-in-Chief at Medical Dialogues. An Economics graduate from Delhi University and a post graduate from London School of Economics and Political Science, her key research interest lies in health economics, and policy making in health and medical sector in the country. She can be contacted at editorial@medicaldialogues.in. Contact no. 011-43720751

      Show Full Article
      Next Story
      Similar Posts
      NO DATA FOUND

      Popular Stories

      • Email: info@medicaldialogues.in
      • Phone: 011 - 4372 0751

      Website Last Updated On : 13 Oct 2022 5:14 AM GMT
      Company
      • About Us
      • Contact Us
      • Our Team
      • Reach our Editor
      • Feedback
      • Submit Article
      Ads & Legal
      • Advertise
      • Advertise Policy
      • Terms and Conditions
      • Privacy Policy
      • Editorial Policy
      • Comments Policy
      • Disclamier
      Medical Dialogues is health news portal designed to update medical and healthcare professionals but does not limit/block other interested parties from accessing our general health content. The health content on Medical Dialogues and its subdomains is created and/or edited by our expert team, that includes doctors, healthcare researchers and scientific writers, who review all medical information to keep them in line with the latest evidence-based medical information and accepted health guidelines by established medical organisations of the world.

      Any content/information on this website does not replace the advice of medical and/or health professionals and should not be construed as medical/diagnostic advice/endorsement or prescription.Use of this site is subject to our terms of use, privacy policy, advertisement policy. You can check out disclaimers here. © 2025 Minerva Medical Treatment Pvt Ltd

      © 2025 - Medical Dialogues. All Rights Reserved.
      Powered By: Hocalwire
      X
      We use cookies for analytics, advertising and to improve our site. You agree to our use of cookies by continuing to use our site. To know more, see our Cookie Policy and Cookie Settings.Ok