A consumer court has directed an insurance company to pay compensation to a policy holder, who was refused reimbursement for the treatment of her pre-maturely born baby on the ground that it did not come within the purview of the policy.
"The insurance company by denying the reimbursement in respect of the pre-mature delivery and the treatment of the child has committed deficiency in service," district consumer disputes redressal forum headed by G D Dhanuka said while directing Oriental Insurance Company to pay Rs 86,501 as compensation.
The complainant, Shikha Jain, a Mediclaim policy holder with the company, was hospitalised with acute jaundice. She was seven-and-a-half months pregnant at the time.
To save the life of the unborn child, her doctors induced labour and a pre-mature male child was born to her.
Both the complainant and her baby were discharged after a month's treatment. Their medical bill came to Rs 86,501.
However, the company agreed to pay only for Shikha's treatment and refused to grant the medical expenses of the child on the strength of an 'exclusion clause' mentioned in its prospectus.
Claiming exception under the clause, the company said the policy did not cover "treatment arising from pregnancy, child birth including caesarian".
However, the court found that the complainant was not duly informed of the fact as the prospectus was never supplied to her.
The company was also asked to pay Rs 3,000 as litigation costs.
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