The District Consumer Disputes Redressal Forum has directed an insurance company to pay Rs 1,54,548 to the widow of an insured person along with Rs 2,000 as litigation expenses.
Earlier, Radhika Soni, widow of Vikas Soni, a resident of Katra Dullo, had filed a complaint against National Insurance Company stating that her husband was insured with the opposite for a sum of Rs 5 lakh.
She said her husband fell ill and was admitted at a hospital in Delhi. She stated that the insurance company paid Rs 50,000 as pre-authorisation but later refused to pay the remaining claim of Rs 1,54,548.
The opposite party in its reply stated that they had already paid Rs 50,000, 50 per cent of the sum insured for any one illness as the sum insured for any one disease was Rs 1 lakh only.
It stated that the claim was declined on the plea that as per the discharge summary, the disease caused was cirrhosis and alcoholic hepatitis alcoholic liver disease. As per the terms and conditions of the policy, the expenses related to the treatment of a disease caused by alcoholic addiction were not payable.
The forum stated that the contention that it being a Parivar Mediclaim Policy and sum insured was Rs 1 lakh only, did not find favour from the fact that the sum insured under the policy was Rs 5 lakh.
It stated that as per terms of the policy, the beneficiary under the insurance cover was entitled to 50 per cent of the sum insured for one illness.
In such a situation, the sum payable would be Rs 2,50,000 whereas the claim of the complainants in the whole came to Rs 2,04,548 out of which an amount of Rs 50,000 had already been paid by the opposite party, stated the forum.
It stated that it appeared that insurance companies showed green pastures to the insured persons at the time of selling the insurance policy and when it came to the payment of the insurance claim, they invented all sort of excuses to deny the claim.
The forum also stated that medical record produced before it stated that Vikas Soni was treated for NASH (Non Alcoholic Steato Hepatitis) which related to non-alcoholic diseases.