Page 49 - Insurance Times July 2016

Complaint No. GI 472 of 2010-2011 ailments denied by the Insurance Company for which he
Complainant: Shri Raman Narayan availed treatment abroad.

V/s As regards, the complainant's plea for reimbursement of
medical expenses incurred in India for Spine surgery under
Oriental Insurance Co. Limited the said policy, Specific condition No. 7 of the Policy is clear
to mention that "no claim shall be paid under the policy in
Shri Raman Narayan took a Travel tag Policy issued by Ori- respect of medical treatment and related services obtained
ental Insurance Company Limited from his travel agent cov- within the republic of India except as stated."
ering his study trip to France and USA. After around 40 days
of his overseas trip, whilst in Michigan, he developed acute Mr. Shaji Sadasivan
back pain and problems of evacuation. He sought medical
assistance from the University of Michigan Hospitals. V/s.

During his treatment, he kept in touch with Coris Miami IFFCO Tokio General Insurance Co. Ltd.
for prior approvals for the treatment which was apparently
not given and later the TPA, Heritage-Mumbai gave their The Respondent had decided to partially settle the claim
repudiation letter rejecting the claim on the grounds that of Motorcar damaged due to accident on the basis of the
complaints had started 1-2 months back. Surveyor's Report treating the damage as partial loss.

The nature of coverage of the policy makes it necessary to The complainant submitted that his damaged jeep was
incur the medical expenses for a sudden and unexpected handed over to the authorised dealer of the manufactur-
sickness or accident arising when the Insured Person is out- ing company and the surveyor has advised to change the
side the Republic of India. The claim also attracts our at- body of the jeep, but the surveyor had submitted his re-
tention on the pre-existing exclusion and condition. port to the Respondent without giving intimation and with-
out obtaining his signature for lesser amount than the ac-
Strictly as per the policy conditions, the Insurance tual charges.
Company's standpoint that the ailment was pre-existing is
acceptable, however, the whole issue being a borderline The Respondent submitted that they had settled the claim
case with symptoms occurring for 1-2 months as recorded based on the surveyor's report after deducting expected
in the hospital papers, would be just before the policy was salvage value.
taken coupled with the fact that the ailment was not iden-
tified or diagnosed before and there being no past surgical This forum also obtained independent opinion from a sur-
history or medications taken except a haemorrhoid steroid veyor who opined that body shell was repairable and not
cream for painful bowel movement as per records, the case required to be replaced. Therefore the Respondent's deci-
deserves some consideration and therefore, 50% of the sion of settling the claim based on their surveyor's report
admissible expenses should be reimbursed in respect of two was upheld. In the result, the complaint fails to succeed.

DHFL Pramerica Life ventures into Health Insurance

DHFL Pramerica Life Insurance has forayed into health insurance business with the launch of dengue protection policy.
"DHFL Pramerica Life Insurance Co. (DPLI) has announced its foray into health insurance segment with the launch of
its first, pure online direct to customer product - DHFL Pramerica Dengue Shield", it said in a statement.

DPLI said it has signed an agreement with ItzCash for customer awareness about the policy by using their over 75,000
retail touch points across India. The company said Dengue Shield is a highly affordable product with premium starting
for as low as Re 1 per day. An individual has the option to choose insurance sum from Rs 25,000 to Rs 50,000.

"This dengue health insurance product will provide meaningful protection to millions of Indians who are exposed to
dengue for a long period of time in the year", Anoop Pabby, Managing Director and CEO, DHFL Pramerica Life Insur-
ance said.

The Insurance Times, July 2016 49