The following are case studies of recent complaints made to the CDRS, and the resulting decisions of the independent adjudicators appointed by the Regulatory Authority.
Reimbursement of medication cost
- Complaint: a firm rejected a reimbursement claim on the ground that the medication is not recommended to be used in treating the medical condition and hence is not covered.
- Finding: the independent adjudicator concluded that the claim should be covered under the terms of the policy. The firm was ordered to reimburse the complainant the cost of the medication.
Reimbursement of delivery cost
- Complaint: a firm partially approved delivery expenses on the ground that the treatment was taken outside the members network hence the Reasonable and Customary charges apply to all treatments taken outside the network.
- Finding: the independent adjudicator concluded that the delivery expenses should be covered in full by the firm.
Cancellation of an investment policy
- Complaint: the complainant entered into an investment policy, which has a lock-in period of two years. After completing the two years lock in period the complainant applied for cancellation of the policy. The firm refused to refund the complainant on the ground that the payment was claimable only from the 25th month of the policy and therefore the client balance is zero.
- Finding: the independent adjudicator concluded that the complainant received misguided information and was provided inappropriate advice hence the firm is required to pay the complainant the total amount contributed.
Reimbursement of medication treatment
- Complaint: a firm rejected a reimbursement claim on the ground that the complainant failed to disclose that he had a pre-existing medical condition prior to taking out his policy.
- Finding: the independent adjudicator concluded that the complainant had a pre-existing condition prior to entering the policy and failed to disclose it to the insurer. Therefore, the complaint was dismissed.