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