Hyderabad: Complaints related to settlement of medical insurance claims rose 2 per cent last year, according to latest data available, with many customers being dissatisfied and approaching consumer courts to settle their claims. The number of litigations has increased to 25,600, compared with 11,000 in 2014-15 and 10,000 in 2013-14. According to the General Insurance Council, which monitors complaints, there was high rate of customer dissatisfaction as they were not willing to accept the settled claims.
Insurance companies in their presentations to the council explained that there was ambiguity and also lack of clarity about policies due to which many customers were confused. “Health insurance policies cover a range of diseases. But there are exceptions which are not covered and these are never read by the customers due to which the problems arise. At the base level, the sales personnel do not explain all these clauses as they want to meet sales targets,” said Mr Prakash Jadhav, senior insurance agent.
Surgeries of ear, nose and throat, cataract, hysterectomy and many others are not admissible in the first 24 months of buying the policy. Many policy holders who discovered this later registered complaints. The industry found that 47 per cent of the complaints were claim-related and 33 per cent were policy related where the customer had not been briefed properly about the clauses. “The exclusion clauses are not very clear. The customer is made to believe that he will get the benefit of medical insurance in diseases that require hospitalisation and for that reason they come forward and contest these cases. In most of the cases, courts have ordered in favour of them as the companies have flawed while selling the policy to them,” said Mr M. Srinivas Rao, advocate with the state consumer forum, said.
Non-specific details have been one of the prime reasons for the increase in disputes. For this reason, the Insurance Ombudsman of India, a quasi-judicial body to expedite consumer cases has 92 per cent clearance in 2015 as compared to 72 per cent in 2014. Settlements to the tune of Rs 505.61 lakh were done in the last three years in the southern states by this body and 69 per cent decisions were in the favour of policy holders and 31 per cent in favour of insurance companies.
Heart of the matter:
Mr Vasudev Reddy, 50, from Kurnool was suffering from a heart ailment. He claimed insurance through the mediclaim of United India Insurance Company Ltd but was rejected; the company stated he was suffering from a genetic disease, which was in the exclusion clause. The National Consumer Redressal Commission stated that this should have been clearly specified to him, which was not done. As they had failed in properly informing the customer, the expenditure of `5 lakh incurred in the hospital must be reimbursed to the policy holder, the commission ruled.
Date issues on policy:
D. Venkata Laxmi, 45, from Shameerpet was suffering from uterus problems due to which she underwent a hysterectomy. The family submitted the documents of the medi claim policy of the Life Insurance Corporation. The hospital processed the bills and asked the family to claim insurance from the company. LIC refused to pay up as the procedure was done within 24 months. The National Consumer Redressal Commission rejected the family’s claim and stated that the policy was very clear about the exclusion clause in their letter. A list of diseases had also been given by the insurance companies.