Pune: The district consumer forum, on Friday, came down heavily on the New India Assurance Co Ltd for its 'high handedness' and 'arbitrary attitude' in not responding to queries from a man who was reimbursed less during his treatment.
Stating that it is an ‘unfair trade practice', the forum ordered the insurance company to pay Rs 50,710, which is the requisite amount, with nine per cent interest since 2015. The company had made a lesser payment, stating that it was not in terms and conditions. The forum also directed it to pay Rs 5,000 towards litigation cost.
Forum President VP Utpat and members Onkar Patil and Kshitija Kulkarni observed that there is no iota of evidence to establish that the terms and conditions incorporated in the policy document were communicated to the insured person.
“It is our general observations that insurance companies come forward with a very attractive policy proposal and lure the customers. The agents of the insurance companies pose the mountain of benefits to the potential insured. But they do not utter the terms and conditions of the policy. They do not explain the exemption clauses to the gullible customers. It is only when claims are submitted to the insurance companies; these companies come up with pages of exemption clauses of terms & conditions and justify the repudiation of the claims. Insurance is a business and contract of utmost faith between the parties. If one party, without disclosing or explaining the terms and conditions to its beneficiary and without bothering to reply the repeated queries of the insured person, takes the benefit of repudiation of insurance claim”, the forum order stated.
Shashikant Gurav, an employee of M/s Ate Welding Engineering Robotics & Automation Private Limited, Pimpri, was covered under the insurance company's Janata Mediclaim Policy for the period March 2014 to March 2015. Gurav was hospitalised from February to March 2015, where he underwent surgery for laminectomy and discectomy. The claim of
Rs 82,210 for hospitalisation and surgery was submitted to the insurance company. However, the firm allowed only Rs 31,500.
The insurance company filed written versions before the forum. “Gurav was allowed an amount of Rs 31,000 for hospitalisation and surgery on the basis of terms and conditions of the policy. The complainant is not entitled to more amounts beyond limits shown in clause number (2.10) of the policy,” the company had stated.