Kathmandu. Non-life insurers cannot reject claim payments on the basis that an insured with accident insurance or health insurance submits a reprint or copy of original bill for medical expenses claim.
The verdict on the complaint filed with the Nepal Insurance Authority (Insurance Committee) on January 1, 2019 has ensured that the non-life insurer cannot reject the claim of the insured on the basis of submitting the copy of original bill.
Govinda Karki, a third-party motorcyclist, was injured in the accident and was treated at the hospital. Laxmi Shrestha had applied for compensation for the treatment at the hospital.
Prudential Insurance refused to pay compensation for the treatment, arguing that it had submitted a copy of original bill.
According to the details of the incident, motorcyclist Govinda Karki was seriously injured when a car (Ba Pra 3246) and a motorcycle (Ga 12 Pa 6125) collided with each other at Swayambhu of Kathmandu Metropolitan City-15 on August 15, 2018. After Karki’s treatment, car owner Laxmi Shrestha had claimed compensation for the third party insurance under motor insurance. For this, she submitted a bill mentioning the copy of original collected from the hospital.
Insured’s claim:
- Third-party motorcyclist injured in car-motorcycle collision{
- All treatment done at Manmohan Memorial Teaching Hospital
- Medicines purchased from a hospital pharmacy
- Received a copy bill when the bill was printed in lump sum after treatment
Insurer:
- Submitted copy bill instead of original bill
- Can’t be compensated based on copy bill
Insurance Committee’s decision:
- The contract of the insurance has a provision to pay Rs 3 lakh or actual expenses
- Copy bill not mentioned not acceptable
- Insurance claim cannot be denied only because a copy bill has been submitted under special circumstances
Prudential Insurance had submitted a written reply to the insurance committee on February 15, 2019, stating that compensation could not be paid for the copy bill as the concerned vehicle owner had submitted a copy bill and claimed it.
The hospital where the injured person was undergoing treatment had sought written information from The Manmohan Memorial Medical College on June 27, 2018. In response, the hospital had informed that on August 15, 2018, the pharmacy unit of the hospital had entered the software earlier, after which it was mentioned as a copy when the patient was printed in lump sum at the time of discharge.
Section 5.6 (a) of Chapter 5 of the Insurance Policy mentions that “in the case of medical expenses incurred directly and as the sole result of a vehicle accident, the necessary and actual expenses” shall not be exceeded to the limit of Rs. 300,000, but it does not appear that the insurer shall provide compensation, but the copy bill to be submitted to the actual bill itself is not acceptable.
The insurance committee has written in the verdict order that in the case of medical claims, it is generally in accordance with the practice of insurance to ask for the actual bill in the case of medical claims, but in special circumstances, it is not logical to deny the insurance claim only because the copy bill has been submitted.
The insurance committee has said in the order that the insurance prudential insurance company should be ordered to make the payment according to section 8 (d1) of the Insurance Act, 2049 and sub-rule 2 of rule 33 of the Insurance Rules, 2049, including the copy of original bill submitted by the insured.
