ISLAMABAD: Federal Insurance Ombudsman, Raeesuddin Paracha orders to pay accumulative Rs.13.7 million monetary relief to policy holders in settlement of their claims, whereas Rs.1.4 million were also ordered to pay to the policy holders in the form of amicable settlement on two different claims filed to this secretariat.

Earlier an NGO “THAR DEEP” had entered an agreement with an insurance company to provide medical facilities for an organized poor community and their members at village level for hospitalization and personal accident. As per policy, respondent company had to provide cover for hospitalization to the insured at its panel hospitals against magnetic swap card but the respondent company provided cash less health services instead of issuing above card. Thus, respondent company failed to fulfil its obligation and defaulted towards its payment to the panel hospitals.

The members of NGOs were refused treatment by the panel hospitals therefore, complainant had to invest huge amount for providing treatment to their members. Thereafter, complainant filed the claim of reimbursement of payment made by them. The respondent company rejected the claim due to incomplete documents of claim which were not sufficient for finalizing the claim.

The complainant approached FIO forum and extensive hearing was conducted by the FIO and he directed in his order that settlement of claim was un-necessarily delayed owing to the inherent weakness which tantamount to male-administration on the part of respondent company and payment of claim of Rs.7.2 million was ordered.

In yet another case, the proprietor M/s. Super Traders filed a complaint for non-settlement of claim of Rs.5.2 million. According to detail, owner lady had obtained an insurance policy under the title of contractors’ plant & machinery. The machinery and other equipments lying on the construction site were stolen by unknown persons. The complainant lodged claim with the respondent company for the compensation of their loss, but the claim was rejected by the respondent company on the plea that incident of loss was occurred at the godown whereas policy covers the construction site only. Complainant referred to the clause of insurance policy in which coverage area was mentioned as anywhere in Karachi. She argued that the coverage was not obtained only to cover the construction site only as basically the purpose was to have a comprehensive risk of damage and theft. In order to compensate the loss of complainant, FIO issued order to make payment of claim amounting to Rs.5.2 million.

In another case, professor Naqvi had obtained a policy of his wife for Rs One Million for natural death. After the death of his wife he lodged a death claim, but the respondent company repudiated the claim by taking the plea that the insured had not disclosed the material facts regarding her health condition at the time of execution of policy.

Eventually, complainant approached FIO forum for the settlement of his claim. After several hearings, FIO in his order observed that the policy was issued through bank assurance channel and no proposal form in writing was obtained from the policy holder at the time of issuance of policy. Further, respondent company failed to establish their instance of non-disclosure and pre-insurance element. FIO issued order to make payment of Rs.1.00 million in lump sum of death claim of Rs.183,000/- as aggregate monthly FIB payment to the policy holder. The respondent company complied with the orders of FIO and settled the claim by issuing cheque of claim to the complainant.—PR