E-Paper
Chandigarh: Consumer court penalises firm for rejecting medical claim
Pawan Sharda from Mansa Devi Complex, Panchkula filed a case against Star Health and Allied Insurance Co, Chennai and Star Health and Allied Insurance Co., Area Office, Chandigarh
The district consumer disputes redressal commission, Chandigarh, has penalised an insurance company, for not paying a claim amount of over ₹6 lakh to a Panchkula resident.
Pawan Sharda from Mansa Devi Complex, Panchkula filed a case against Star Health and Allied Insurance Co, Chennai and Star Health and Allied Insurance Co., Area Office, Chandigarh.
Sharda alleged that he obtained health insurance policy from Star Health and Allied Insurance Company through its area branch in Chandigarh for himself and his family for the period from October 2020 to October 2021.
He was taken to Fortis Hospital Mohali, after he fell ill during work in July 2021. He was fully insured for his medical cashless policy and he was sanctioned ₹10,000 by insurance firm. He submitted a claim for ₹6,27,449 to the insurance firm. However, in that letter the diagnosis was “Meningitis” and the doctor specifically mentioned in the letter that “viral meningitis is not related to alcohol intake”.
However the claim was rejected on the basis of wrong diagnosis and observation and that the complainant was the patient of “Acute Delirium, Wernicke Encephalopathy”.
In the tribunal, the firm contested that from the submitted medical records, it is observed that Sharda is a chronic alcoholic. The firm added that as per their policy, Sharda is not liable to make any payment in respect of expenses incurred at hospital for treatment for alcoholism, drug or substance abuse or any addictive condition and consequences thereof. Hence, the claim was rejected.
After scrutinising the records, the forum observed that the disease which the complainant developed admittedly had no nexus with the intake of alcohol, as per doctors. “Therefore, much credence could not have been attached to the stray sentences written in the medical history of the patient by the doctor regarding intake of alcohol,” it adds.
The order mentioned: “Alcohol in itself is not a poison if taken in small quantities as it is a mixture of water, sugar and fermenting agent. In other words, it is a sugar content and, if taken in limit, it cannot be said he was an alcoholic or it could have caused the disease with which the complainant suffered. Thus, there is a clear-cut case of deficiency.”
The forum directed the opposition parties to pay ₹6,27,449 along with interest of 9% per annum from the date of repudiation till realisation. Also, to pay ₹15,000 for causing mental agony and harassment to him and to pay ₹10,000 as costs of litigation.
