CERS compels public sector insurer to settle claim of Rs 80 lakh previously rejected on invalid grounds
Ahmedabad, June 06 th , 2013
A tactical move by a government-owned general insurer to reject a valid claim of an amount as high as Rs. 80 lakh by making convenient interpretation of the terms & conditions of the insurance policy was blocked by intervention of nationally renowned consumer organization Consumer Education & Research Society (CERS), which filed a case on behalf of a city-based firm in Consumer Disputes Redressal Commission, Gujarat and got an order in favor of the complainant for the settlement of the claim. The State Commission ordered New India Assurance to pay Rs.80 lakh within 30 days with interest at the rate of 9% and also asked to pay additional amount of Rs. 50,000/- towards the litigation cost and Rs. 1,00,000/- as compensation for the mental agony faced by the complainant.
As per the case details, Doshion Ltd. providing solutions for water management, received a contract for installation of a desalination plant on turn-key basis from Kerala Minerals Metal Ltd in 2005. As prescribed in the bid document, the company got a standard fire & special perils policy covering risk of Rs. 29.25 crore including cover of Rs. 5 crore for construction materials and other stocks before commencing the work in 2006 from New India Assurance Company Ltd by paying a premium of Rs. 8.08 lakh.
Thereafter, during the progress of the work, the construction site was flooded by the sea water due to breach in a nearby earthen embankment and whole machineries and material mobilized for the work were destroyed. The development was immediately reported to the insurance company. As per the evaluation, the damage was to the tune of about Rs. 80 lakh and Doshion Ltd put up a claim of Rs. 86.93 lakh before the insurer. However, the claim was rejected saying that the site, where the damage was done, was different one from the place cited in the insurance policy.
As the move was illegal, Doshion Ltd approached CERS to intervene. After verifying all the details, CERS filed a complaint in the Consumer Disputes Redressal Commission, Gujarat State, Ahmedabad. On behalf on CERS, Mr. Apurva Dave appeared in the Commission. After hearing both parties through their counsels, the Commission rejected the argument made by New India Assurance company and passed an order in favor of the complainant asking the insurer to suitably compensate.
For further details please contact: Mr Apurva Dave, +91 98255 55854
What you would like your life insurance policy to achieve?
Ask yourself what it is you want the insurance to do. For example, do you want to have coverage that will:
Pay the outstanding balance owing on a mortgage and other debts?
Offset the loss of your income? For how long?
Contribute to the future education of your children?
A combination of all or part of the above?
Knowing what you would like to accomplish with your life insurance policy will help you determine how much life insurance you need to buy. If you have insurance before then what is the purpose of the new policy? What value will it add to existing policy? Why are you buying the policy?
Who would you like to insure?
Most life insurance companies offer a variety of products to suit your lifestyle and family. You can get a life insurance policy
On your own life, or
You can get one policy for both you and your spouse (called a joint life insurance policy) or
For your child.
Click Here for the detailed article with some interesting do’s and don’ts
Reliance Life Insurance had mis-sold ULIPs worth Rs12 lakh. Moneylife had taken up the issue with IRDA and written cover story on it. Justice is served with return of investment along with Rs1.75 lakh interest, which is about 7.5% per annum
Click Here for the full story
Ahmedabad, 10th November, 2012: The Consumer Disputes Redressal Forum, Ahmedabad (Additional), has directed Oriental Insurance Company Ltd. to pay its valid health insurance policyholder Chirag Sanghavi Rs. 1.17 lakh, part of it with interest, for the expenses incurred by him on his medical treatment. The amount includes compensation of Rs. 10,000 for his mental agony and Rs. 2,000 towards the litigation cost. Consumer Education & Research Society (CERS), a co-litigant with Sanghavi, was also awarded Rs. 2,000 towards cost.
Sanghavi had been suffering from Crohn’s disease and, on 22-23 September 2005, had been treated at the local Dr. Jivraj Mehta Hospital. Only the previous month he had purchased a medical insurance policy from Oriental Insurance. But he did not make any claim since, as per the conditions, the company was not liable to pay any cost for treatment taken during the first six months of the policy.
On 5 August 2006 Sanghavi renewed the policy for another year. On 2-3 September 2006, he had to undergo treatment once again. This time, he was given Remicade – IV injection and was hospitalised for one day. On release, he claimed reimbursement of the total cost of Rs. 1,50,299. The insurance company settled only part of the claim, i.e. Rs. 44,826, saying the treatment did not require hospitalisation and so the entire cost was not payable.
Sanghavi made a representation to the company that in the opinion of the doctor who had treated him, hospitalisation was required as the dose of the injection might lead to certain side effects. But the company declined to agree. Sanghavi approached CERS, which filed a complaint in the consumer forum seeking reimbursement of the deducted amount along with interest, compensation for the mental agony faced by the complainant and the cost.
The insurer cited the opinion of a doctor from a third party agency (TPA) that since no side effects had been noticed when Sanghavi had been treated for the first time, hospitalisation was not required during the second time. CERS quoted the doctor who had actually treated the patient that no-reaction during the first course of treatment did not necessarily eliminate the risk involved when the procedure was repeated a second time and, therefore, hospitalisation was absolutely necessary in this particular case.
The forum observed that the opinion of the doctor treating the patient was more important than that of the doctor serving a TPA. The forum ordered the insurance company to pay Rs.1,05,473/- from 29 June 2007 @ 4% interest. It also directed the company to pay Sanghavi Rs. 10,000 for mental agony faced by him and Rs. 2,000 each to him and CERS towards the litigation cost.
For more information please contact Ms. Pritee Shah (O) 079 -27489945/46
Road accident victims may lose their lives or end up disabled. While physical abilities are irreplaceable, financial compensation would alleviate the victims’ problems. Raj Pradhan reveals the many details of how such financial compensation can be obtained and also the best-kept secret of accidents involving drunk drivers.
Considering such low premiums for unlimited liability cover, it is inexplicable that 5% of vehicles on the road do not have valid insurance. This goof-up is more for two-wheelers than cars—even more baffling, considering that the TP premium is a pittance for two-wheelers. A two-wheeler can cause as much damage as cars; there is no justification for not buying the mandatory TP liability insurance. There is no grace period after the insurance term gets over and you lose the no-claims-bonus (NCB) if you fail to renew before policy expiration.
The TP liability cover, which is mandatory in India, does not provide any benefit to the insured; however, it covers the insured’s legal liability for death/disability of third party loss or damage to third party property. MACT is a tribunal in which the cases related to road accidents are decided and appropriate compensation is given to the victims or their next of kin. MACT courts are presided over by civil judges from the state higher judicial service and come under direct supervision of the High Courts.
It may be hard to believe, but one can get compensated by the insurance company for accidents occurring from drunk driving. According to Avadhoot Mavlankar, principal officer, Shinrai Insurance Broking, “Motor Vehicle Act, 1988 in India is considered a strict law by the insurance companies. Insurance is a contract between the insurer and the insured. There is no privity of contract between the insurer and a third party who suffered in an accident. The law gives the insurance company a limited right to defend against a third party. Even if the car driver is drunk, and at fault in an accident, MACT will give compensation to the third party, and it will have to be paid by the insurance company. In 99% of cases, the insurer will not be able to recover the money from the insured.”
Click Here for the full detailed story.
Insurance is easy to buy but tough to claim, if you are an individual. Raj Pradhan narrates a real-life story that takes you through the labyrinth of insurance company, broker, TPA and hospital to explain how to make a valid claim and how to avoid going out of pocket
* Our second lesson was that brokers are also not very savvy about the rules and you need to know them yourself.
* A third learning was that even if you have a cashless facility, the cost of registration as well as initial consultation and tests have to be borne by the patient.
* Our fourth learning was about finding out the cost of procedures and tests.
Click Here for the detailed update.
Right from claim settlement to getting a cashless mediclaim, policyholders have to face a lot of problems in getting their dues under a health policy. Moreover, there are stringent deadlines to be met by the policyholders in filing their medical claims; which if they (insured) fail to meet, claims are declined by the insurers. Also, until now the insurers are not mandated to provide the reason for denial of claims to the insured.
Citing such problems faced by the insured or policyholders, the insurance regulator – Insurance Regulatory and Development Authority (IRDA) has laid out a slew of changes in the insurance industry under its draft guidelines.
Let us delve deeper into the sweeping changes brought about by the IRDA
Click Here for the full article