Prior to order, third party administrator had rejected the Rs 7-lakh claim twice, insisting that injuries due to mountain rappelling weren't covered by the mediclaim
Narayan Ladha has had to wait a long time for this — for over two years. In November 2010, his son Yash, a first-year BMS student, fell thirty feet while mountain rappelling with friends in Silvasa. He suffered multiple fractures to his limbs, and required extensive surgeries and admittance twice at Bombay Hospital. Total expenses came to around Rs 7 lakh. Fortunately, or so he thought, Narayan had obtained medical insurance for his whole family.u00a0
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Hard-earned: Narayan Ladha (below) had to fight for two years before his insurance company paid up Rs 7 lakh incurred in the medical treatment of his son Yash. Yash Ladha was injured during a mountain rappelling event in 2010
“The claim was passed on to Raksha — the third party administrator (TPA) — who promptly rejected it, stating that mountain rappelling was classified as a hazardous sport, and injuries sustained therein were not covered under the policy (MiD DAY has a copy of the letter),” informed Narayan. He added that this was totally absurd as the event was organised by a reputed Rotary Club, where more than 120 children participated under the watchful eyes of 18 qualified coaches.
“It was unfortunate that my son’s safety harness snapped and he fell. Had it not been for legal guidance and the professional attitude displayed by the Ombudsman, ours was a totally lost cause,” he said and added, “In fact, interestingly, the TPA rejected our second claim even before we had filed it. I have mediclaim for my entire family since 1994 and pay an annual premium of about Rs 2 lakh. This is the first time that we have made a claim and have had to face all these hassles.”
Quest for justice
Social activist and legal advisor Richi Sequeira, who was approached by Narayan for guidance, represented the matter before Insurance Ombudsman S Viswanathan (now retired).
“Mountain rappelling, which is controlled descent down a rock face using a rope and safety harness, can best be qualified as an adventure sport. It falls under mountaineering, which is recognised by the ministry of sports. This point was put across to the Ombudsman, who fully agreed with us and instructed the insurance company to pay the entire claim amount,” observed Sequeira. The Ladhas received the full payment last week.
Sequeira maintained that even Bombay High Court observed this on Monday that insurance companies, which give incentives to TPAs to reduce claims, are working against consumer interests, and has allowed Insurance Regulatory and Development Authority — the administrative agency of Government of India for insurance sector — to finalise its draft regulations, which would give more powers to the Ombudsman and include imposition of penalties on erring insurance firms.
Strings attached
When contacted, R K Verma, secretary, Insurance Ombudsman, who was present for the hearing observed that the insurance companies and their TPAs have to be more sensitive in handling claims.
“It is obvious that insurance companies are more aware of rules and regulations compared to their clients. It is therefore important that the person purchasing the insurance or mediclaim reads and understands the fine print, before signing on the dotted line,” he said.
When the mobile number mentioned on Raksha TPA was dialled by this reporter, a person who identified himself as Santosh said that he was in Pune and unaware of this case.
When contacted, Dr SC Mohanty, divisional manager, New India Assurance, said that Ladha had not provided the entire paperwork at the time of registering the claim, so the matter was handed over to the TPA and finally the dispute had to be settled by the Ombudsman.
“Rappelling is an adventure sport and not covered under mediclaim if not done under expert supervision. Narayan had to produce the requisite papers to prove the same, as per the orders of the Ombudsman,” he said. u00a0
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