Manish Chadha, a Pune-based hotelier, has won a case against Bajaj Allianz General Insurance Company Ltd (BAGICL) — which refused to entertain his medical claim — before the Insurance Ombudsman (Maharashtra and Goa).

Chadha had chosen to approach the insurance ombudsman instead of the district consumer forum after the insurance company refused to acknowledge that panic and anxiety, for which he was treated, were not the commonly perceived psychiatric disorder but a condition arising out of cardiac complications. “All these when the company itself had settled a similar claim in 2008,” Chadha said.

Chadha, who also owns a legal consultancy firm, was at a popular jewellery shop on Karve Road on October 5, 2010, when he started to sweat profusely, had severe palpitations besides suffering giddiness. “I was rushed to the nearby Sanjeevan Hospital and was discharged the next day. The discharge card stated ‘panic disorder and anxiety’ and advised Chadha to do a cardiac review from Jehangir Hospital as the required equipment was not available there.”

Chadha filed a claim under the Health Guard Policy for Rs 8,311 with a copy of the discharge card and other documents on October 7. The company repudiated the claim, citing ‘Psychiatric illness/ psychiatric treatment’ that is excluded from the policy. “I wrote back to them and attached letters from Sanjeevan Hospital’s doctors that the panic disorder and anxiety were related symptoms to cardiac ailments and that I was not given any psychiatric treatment,” he said. ”Though the amount was not big, I decided to pursue the claim because of discrepancies shown by BAGICL. After I filed the claim, I received a letter on October 25 asking for more documents. Within 24 hours, the same person sent me another letter repudiating the claim.”

On December 28, 2010, Chadha received another communique from the company that he needs to complete the cardiac review in Jehangir Hospital. Though the cardiac review reports indicated ‘sinus tachycardia’ as the final diagnosis, the company continued to refuse the claim.

Chadha approached the Insurance Ombudsman (Maharashtra and Goa) in Mumbai on November 10, 2010. Assistant manager Vikram Ravindranathan and Dr Rashmi Sachdev represented BAGICL before Insurance Ombudsman S Vishwanathan.

After hearing both sides, the Ombudsman — in the order dated July 29, 2011 — observed that Chadha’s case was of ‘tachychardia manifested by way of severe palpitations and increased heart rate with panic attack which cannot be termed as ‘psychiatric illness’ and hence repudiation of the claim was not justified.’ The Ombudsman directed the company to settle the claim of Rs 8,311 and pay the balance of Rs 1,000 under cash benefit scheme within three working days.

Sudhakar Velankar, former president and trustee of consumer rights’ group Grahak Hitvardhini, said the case was important considering that the decision came from the ombudsman. “Only a few people approach the insurance ombudsman and the percentage of cases disposed in favour of the consumer is even lower.”

Source -