Insurance companies do not take proper care in processing health insurance claims and reject insurers’ claims on one pretext or another. In many cases, when the insured customer later complains in court, the insurance company itself takes a U-turn from the earlier decision and settles the claim amount with the insured. Padmaben Paneerwala, a resident of Syedpura area in Surat, has had a similar experience recently.
Padmaben Paneerwala (Plaintiff) through Advocate Shreyas Desai and Advocate Ishan Desai. Max Bupa Health Insurance Co. Ltd. In the case filed before the District Consumer Disputes Redressal Commission of Surat against (Samawala), it happened that the plaintiff had taken his health insurance from Kas Bupa Health Insurance with Rs. 5,00,000 / – was taken. While the text insurance was in force, Shri. Dr. at KPSanghvi Hospital. Dhawal Desai conducted a clinical examination of the complainant. Admitted as Indoor Patient on 16/01/2020. Subsequently, the plaintiff underwent various tests as per medical advice. In the text report, the plaintiff was diagnosed with PFN For Left Per Trochanfenic Fracture. So that Dr. Dhawal Desai advised the plaintiff to undergo surgery. Where the next day i.e., Ta. On 17/01/2020 Dr. The plaintiff underwent surgery by Dhawal Desai and was also given necessary treatment. Then Ta. The plaintiff was discharged from the text hospital on 23/01/2020.
The total cost to the plaintiff is Rs. 1,36,825 / -. So that the plaintiff can fill the prescribed claim form of the insurance company with the same. (1) Claimed before the insurance company. However, the insurance company denied the plaintiff’s claim, stating that the plaintiff had hypertension for 20 years before taking out the insurance and had concealed the fact while insuring. On behalf of the plaintiffs, advocates Shreyas Desai and Ishan Desai had submitted to the plaintiff that the plaintiff’s claim was not payable 20 years ago and the hypertension had nothing to do with the plaintiff’s hip surgery.
The insurer’s negligence in rejecting the hip surgery claim by incorrectly associating it with hypertension has led to a loss of service and negligence on the part of the insurance company, claiming that the so-called hypertension did not cause any problem or need for surgery in the hip. But before the final hearing in the case, the insurance company took a U-turn from its position and paid the plaintiff Rs. 1,28,020 / – was offered as settlement. The plaintiff accepted Samawala’s text offer and the Samawala insurance company paid Rs. 1,28,000 / – has been paid to the complainant.
