The National Consumer Disputes Redressal Commission (NCDRC) recently upheld a ruling compelling Oriental Insurance Co Ltd to disburse Rs2,73,000, alongside 9% interest annually, for a knee replacement treatment. This decision stemmed from Oriental Insurance’s failure to communicate the terms and conditions (T&C) of the mediclaim policy to the complainant.
Concurrent Findings
The NCDRC, in its recent ruling, supported the decisions made by lower fora in favor of the complainants. The commission acknowledged the absence of communication regarding policy terms, specifically the exclusion of osteoarthritis from coverage, to the insured party.
Lack of Communication
Despite Oriental Insurance’s contention that policy terms were included in the prospectus, a crucial document, the bench noted that relevant spaces for endorsement, including signature areas, were left blank. This oversight indicated a failure to inform the proposer adequately.
Case Background
Dr. Ram Kumar, hailing from Sangrur, Punjab, initiated an insurance claim for his wife Renu Bala’s knee replacement treatment. The treatment, conducted at Raffels Hospital, incurred expenses totaling Rs2,75,000. The insurance policy, ‘PNB Oriental Royal Mediclaim Policy,’ mandated Oriental Insurance to directly settle hospital bills due to its cashless nature, a responsibility left unmet.
Lack of Response
Despite numerous pleas from Dr. Kumar, Oriental Insurance remained unresponsive to requests for claim approval. Legal notices and reminders sent by Dr. Kumar’s counsel received no acknowledgment until a third-party administrator (TPA) responded, dismissing the non-payment as non-deficient service.
Repudiation
Oriental Insurance eventually repudiated the claim on technical grounds. Dr. Kumar, dissatisfied with the wrongful repudiation, filed a complaint before the Sangrur district consumer disputes redressal commission, which ruled in his favor, directing Oriental Insurance to pay the claim along with additional costs.
Legal Proceedings
Following an unsuccessful appeal by Oriental Insurance before the Punjab State Consumer Disputes Redressal Commission, the case reached the NCDRC via a revision petition.
Decision
NCDRC dismissed Oriental Insurance’s revision petition, emphasizing the insurer’s failure to furnish conclusive evidence of policy communication. The commission directed Oriental Insurance to fulfill the claim as per the district forum’s order.
Conclusion
The case underscores the importance of transparent communication between insurers and policyholders. Failure to convey policy terms and conditions can lead to legal ramifications, as evidenced in this instance.
