A consumer forum here has asked an insurance firm to pay over Rs 92,000 to a man for repudiating medi claim for his son's treatment, saying its action was arbitrary.
New Delhi Consumer Disputes Redressal Forum, presided by C K Chaturvedi, asked the Oriental Insurance Company Ltd to pay Rs 92,696 to Delhi resident Sachin Tayal, who had sought medical after his his minor child was admitted at a hospital here for removal of adenoids (enlarged lymphatic tissue) on January 31, 2011.
The company, however, turned down the claim on the ground that as per policy congenital defects are excluded, and that complaint of snoring, fever and difficulty in hearing were pre-existing diseases.
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In its order, the forum noted that the problem for which complainant's son was admitted in the hospital was not a disease but medical condition.
"...The adenoids in children is a common phenomena leading to fever, difficulty in hearing as ear, nose, throat are interconnected, and the treatment is only removal of growth of soft tissues in throat and insertion of grommets in ears. These are not diseases but medical condition. In no case it can be called congenital disease," it said.
"...We find that Opposite Party (company) has not applied its mind and arbitrarily repudiated a just claim," the forum's bench, also comprising its members S R Chaudhary and Ritu Garodia, said.
The forum held the company guilty of deficiency in service. It directed the firm to pay the claim amount of Rs 47,696, besides Rs 25,000 for deficiency, harassment and mental agony and Rs 20,000 for the litigation
Tayal had told the forum that he, along with his son, was insured under Medi claim policy of the company since September 26, 2007.
