A subject of Insurance policy

Have you been waging a battle against insurance firms who do not honour promises? Keep heart. You are part of an army.

About two-thirds of the complaints received in the 5 consumer courts in Mumbai, Navi Mumbai and Thane in the last 4 years are insurance-related. Out of 1,488 complaints, 969 are against insurance firms, 299 against manufacturers of home appliances and consumer goods, and 220 against airlines and travel agencies.

Among insurance-related complaints, those pertaining to health insurance number more than the ones pertaining to vehicle insurance. A case in point is the South Mumbai consumer redressal forum, where 256 medical insurance and 116 vehicle insurance claims were filed from 2007 to 2010.

Consumer issue experts say the numbers exemplify how difficult it has become for policyholders to get medical insurance reimbursements. "Many cases related to medical claims come to consumer courts these days. Most are rejected on weak grounds like pre-existing disease and reasonability (of medical charges)," said consumer activist Jehangir Gai. "But there is a very good chance of consumers to win their cases if they approach the court with the relevant documents."

He said that through the reasonability clause, insurance firms try to level a policyholder over how much money a doctor can charge. He said he recently fought a case where the insurance firm rejected a chemotherapy claim for a cancer patient. "The insurance firm paid for three sessions but not the fourth. It said it would not incur the cost for outpatient treatment. But I won the case for the patient as the policy clearly says the clause is not applicable for chemotherapy."

Chetan Kothari, an activist who filed an RTI query on this issue said medical claims were rejected despite a stipulation by the Insurance Regulatory Development Authority (IRDA) that it was mandatory for doctors appointed by insurance firms to test customers before giving them policies. "Their own doctors are unable to discover pre-existing diseases. But when a claim is filed, the firm calls the disease pre-existing."

Rajan Alimchandani, a resident of Worli who had fought a medical claim case, said many policyholders do not know that IRDA rules state that if an insurance firm did not send objections to a claim within 15 days of it being filed, then the objections become invalid. "I fought a case where an insurance firm had rejected free medical check-up, which was part of the bonus package in the policy. Many policyholders do not even know they can avail of this facility."