Ahmedabad: The District Consumer Disputes Redressal Commission (main), Ahmedabad, has directed United India Insurance Company Limited to reimburse Rs 1.2 lakh that it deducted from a policyholder’s Covid-19 hospitalisation claim. The commission held that the insurer had failed to justify the deductions under the terms of the Mediclaim policy.The commission also ordered the insurer to pay 8% annual interest on the deducted amount from Feb 5, 2021, along with Rs 5,000 as compensation for mental agony and Rs 3,000 towards litigation costs.The complaint was jointly filed by the Consumer Education Research Society (CERS) and the policyholder, Kishore Trivedi.According to the complaint, Trivedi, who was covered under a policy with an insured sum of Rs 4.25 lakh, was admitted to hospital for Covid-19 treatment between Dec 23 and 27, 2020. His treatment cost Rs 2.24 lakh. While the insurer settled part of the claim, it deducted Rs 1.20 lakh, contending that the hospital’s charges exceeded guidelines issued by the Ahmedabad Municipal Corporation and that certain specialist consultations were not adequately justified.Rejecting the insurer’s stand, the commission held that the company had failed to identify any clause in the policy permitting such deductions or imposing a ceiling on investigation charges.“Once an insurer accepts liability under a policy up to the insured amount, it is contractually bound to reimburse admissible medical expenses. A hospital providing treatment cannot be held responsible for the insurer’s liability under the insurance contract,” the commission observed. It held that the deductions amounted to a deficiency in service and an unfair trade practice.The commission directed the insurer to comply with the order within one month. It said that if the amount was not paid within the stipulated period, the insurer will be liable to pay an additional 2% annual interest until the dues were realised.
