PRESS NOTE Consumer Forum: Discrimination between cashless and non-cashless (mediclaim) should not be permissible ---------------------------------------------------------------------------------------------------------------In the

instant case complainant is covered under the Mediclaim Policy of one insurance company since 10 years and during these last 10 years, there is neither a break nor any claim towards the policy. On 29/08/2011 the daughter of complainant was admitted in a Hospital for the treatment of Dengue fever for which the complainant was applied for cashless facility through the said hospital and the same was approved by the TPA. Then, after two days on 01/09/2011 the son of complainant was also hospitalized in the same hospital for the same disease (Dengue Fever) and the complainant again requested for the cashless facility to TPA through his hospital, however, this time TPA did not approve the cashless facility on time, and by the time the complainant received the AL (Authorised Amount / Approved Limit) for just Rs.8000/= from the TPA and as it was too late as the son of the complainant had already got discharged from the hospital, the complainant had to pay all the bills of hospital etc.. Thereafter, the complainant submitted the claim file amounting to Rs. 24,337/= with the TPA and the said TPA harassed the complainant by raising unnecessary queries and documents since long and did not settle the claim on time for which the complainant also wrote to the Sr. Divisional Manager of the insurance company. Complainant was shocked and surprised when the complainant got the Claims Payment Statement Non Cash Less Claim (Claim Settlement Note/ Voucher) along with the cheque of just Rs. 6635/= against the Total Claim Amount of Rs.24,337/= . It is quite shocking and surprising to know that for one child of the complainant the insurance company approved the full claim via cashless i.e. 25,500/= and for the second child of the complainant they just approved Rs. 6635/= via non-cashless, though both were suffering from the same disease and were hospitalized in the same hospital and that too within 2-3 days under the same policy & period. Not only this, the TPA also harassed the complainant by; Not granting the cashless facility on time Raising unnecessary queries Kept claim pending even after getting reply of query by hospital Kept claim pending even after providing a hard copy of reply 1

not settling the claim properly.

Complainant thereafter filed Grievance regarding the same but met with no success. The claim of the complainant was genuine and was for the period of the hospitalization which was not in dispute and because of not proper settlement / disallowing of the aforesaid claim which was to the tune of Rs 24337/= complainant has caused serious hardships. Insured, thereafter had no alternative but to approach the consumer forum In reply, insurance company neither replied about on what grounds, reasons, rules, regulations, terms etc. they did not approved the Cashless facility for the complainant's second child nor even did they approved the full claim. The insurance company was also not replied about on what grounds, reasons, rules, regulations, terms etc. they have approved the Cashless facility for the complainant's 1st child for Rs.25,500/= (i.e. insurance company approved the full claim via cashless i.e. 25,500/=) Whereas in the case of the complainant's son, the respondents have approved the AL (Authorised Amount / Approved Limit) just for Rs.8000/=, even after knowing and verifying the records that the Complainant is covered under the Mediclaim Policy since last 10 years and during these last 10 years, there is neither a break nor any claim towards the policy. In this case immediately after 2 days of daughter's hospitalization, the complainant's son was also hospitalized in the same hospital for the same disease (Dengue Fever) and the complainant requested for the cashless facility to TPA through his hospital. However, this time TPA, did not approve the cashless facility on time, and by the time after so many attempts and prayers the complainant received the AL (Authorised Amount / Approved Limit) just for Rs.8000/= . Again it was too late as the son of the complainant was already discharged from the hospital and the complainant had to pay all the bills of the hospital etc. Not only this, but the TPA also harassed the complainant by; not granting the cashless facility on time, raising unnecessary queries, keeping the complainants claim pending even after getting reply of the query by the hospital, keeping complainants claim pending even after getting a hard copy of reply and not settling the claim properly. Under such circumstances, it is beyond the complainant's understanding that on what grounds, reasons, rules, regulations, terms etc. the respondents have done so. The objections raised by the insurance company were not substantiated and were mere reproduction of the clause of the policy and calculations in non-cashless system. Insurance companys settlement was not acceptable to the complainant since the insurance company has not made complete payment of the claim amount and has taken different stand for two similar claims under the same policy. The 2

action of the insurance company in not proper settlement / disallowing the claim is quite shocking and surprising, Under the same policy the insurance company has taken different stand for two similar claims under the same policy and therefore the same cannot be permitted being discriminatory and therefore the benign interference of Hon'ble consumer forum is required in the matter. Dont you think that, the insurance company and the TPA should be directed to refund all premiums paid to them towards all the policies since 10 years and TPA who is also getting 6% to 10% from that, and if they are not capable to indemnify the insurance business for settling the claims on time then must Quit from it, the insurance companies have to Perform on time or Perish. The insurance companys discriminatory action of approving or disallowing the claims as in case of Cashless or Non-Cashless claims of same disease covered under the same policy cannot be permitted, since the action is discriminatory, illegal, illogical, not valid, and against the interest of the consumers. Therefore, the consumer forum have allowed and admitted the complaint of the complainant in the interest of justice.

By:

manohar makhija

(Panel No.4, Gujarat Gandhinagar) Office No. 14, Grd Flr, Sarthak Towers, Nr. Ramdevnagar Crs Rd, Satellite, Ahmedabad-15 (M) +91 094264 06046, E-mail: manohar.makhija @ yahoo.co.in

(advocate & Inquiry Officer) Registrar of Co-Operative Societies,

State-