Insurance Ombudsman settles Covid policyholder's claim

Mumbai The Insurance Ombudsman of Mumbai and Goa, Milind Kharat, has directed the private sector non-life insurer, Universal Sompo General Insurance to settle the claim for the balance amount of Rs 15,700 plus wrongly deducted co-pay of Rs 18,879 in respect of Jayaben Shah's claim and additional amount Rs14,300 plus co-pay of Rs 26,170 in respect of Ramniklal Shah towards full and final settlement of above two claims subject to availability of sum insured and inform the payment particulars to the Forum.

The order was issued on April 30 and the complainant is Manish Shah. Bizz Buzz is having a copy of the order. The order was issued under provisions of the Insurance Ombudsman Rules 2017. As per Rule 17(6) of the said rules the insurer shall comply with the award within thirty days of the receipt of the award and intimate compliance of the same to the Ombudsman. As per Rule 17(8) the award of Insurance Ombudsman shall be binding on the insurers.

Jayaben Shah, mother of the complainant, insured under a policy was admitted at Harilal Jaichand Doshi GHS Hospital from October 10, 2020 to October 11, 2020 for treatment of Covid-19. The total claim of Rs 1,51,239 was lodged which the company settled for Rs 74,393 while deducting the balance amount on the ground of proportionate deductions, non-payables and co-pay.

Ramniklal Shah, father of the complainant was also admitted from September 25, 2020 to October 7, 2020 in the same hospital for treatment of Covid-19. The total claim of Rs 1,54,262 was lodged and the company settled the claim for Rs 89,355 having deducted the balance amount on the ground of proportionate deductions, non-payables and co-pay. The complainant has represented in his written statement that he is not agreeable with the decision of the company.

The complainant submitted during the hearing that his parents both mother and father were diagnosed with Covid-19 and were admitted at Harilal Jaichand Doshi GHS Hospital. Claims of Rs 1,51,239 and Rs 1,54,262 were lodged with the company who settled them for Rs 74,393 and Rs 89,355 respectively. Residual amounts were deducted on the ground of proportionate deduction, non-payables. It was also alleged that the respondent had wrongly deducted co-pay in both the claims. He stated that these deductions are not acceptable to him and he requested for settlement of this balance amount.

The respondent submitted during the hearing that they are now ready to consider payment of co-pay of Rs 18,879 in respect of Jayaben Shah's claim and an amount of Rs 26,170 in respect of Ramniklal Shah.