Delay in group insurance premium can’t hit individual

Surat: In an important judgment with regard to the group medical insurance policy, the Valsad District Consumer Dispute Redressal Commission observed that individual policy holder’s risk cover in such group policies cannot start only after the insurance company receives the premium. The commission said there may be a delay in the process of collecting all employees’ premium and depositing the bulk amount by the company or department in the bank.

Going by its observation, the consumer court ordered Oriental Insurance Company Ltd to reimburse Valsad-based head constable (Armed), Haresh Desai, his mediclaim amount of Rs 1.5 lakh with seven percent interest effective from September 2017. It also awarded compensation of Rs 2,500 Desai.

Paramount Health Service (TPA) Pvt Ltd denied paying Desai the claim amount stating that when the cop had taken treatment, the police department did not pay the premium for the policy and it was paid much later. The consumer court also observed that in group medical insurance policy, risk cover exists till the fixed date.

According to case details, Desai, a resident of Bhutsar village in Valsad district, approached the consumer court alleging Oriental Insurance Company Ltd and its TPA (Paramount Health Service and Insurance Pvt Ltd) denied reimbursing his claim for medical treatment. Desai had also made Valsad SP and DGP (Gujarat) office as party to his complaint.

Desai argued that insurance premium amount is being deducted from his salary by the police department as part of his service and group medical insurance policy. This amount is paid to the insurance company and its TPA. He stated that Rs 3,354 had been deducted from his salary in September, 2015 against his policy period that started from August 01, 2015.

During this policy period, Desai fell sick on November 21, 2015 and had to be operated upon after which he was discharged on December 03, 2015. The medical bills for his treatment came up to Rs 6.13 lakh and he later filed a claim for the reimbursement from the insurance company. However, it was denied.

Manager of Paramount Health Services argued that Desai’s policy started from August 01, 2016 whereas he had taken treatment in 2015. Therefore, his claim can’t be reimbursed as his medical insurance cover starts only after the company receives a premium. When Desai took treatment, his premium was unpaid rendering him ineligible for reimbursement.

Desai’s advocate argued that a card from the insurance company was provided to his client which states that the policy period starts from August, 01, 2015. Desai also produced documentary evidence of premium for his policy being deducted from his salary in September, 2015. The company also said that it had received a premium on November 30, 2015, but did not reveal when the TPA deposited the premium amount to the insurance company.

Source: The Times of India