Chandigarh: Insurer gets a bitter pill, fined for rejecting mishap victim’s claim

The District Consumer Disputes Redressal Commission, Chandigarh, has directed Niva Bupa Health Insurance Company Ltd to settle the complainant’s full medical bill of ₹1,33,946, along with interest at 9% per annum from the date of repudiation of claim

A health insurance company has found itself in soup for rejecting an accident victim’s medical claim, citing non-disclosure of pre-existing disease.

On June 8, 2019, the complainant met with an accident at the Mumbai railway station. After mild treatment at Mumbai, he was admitted to Max Hospital, Mohali, where he was treated for factures and discharged on June 13, 2019. (Getty Images/iStockphoto)

Observing that the pre-existing disease has no connection with the treatment availed for injuries suffered in the accident, the District Consumer Disputes Redressal Commission, Chandigarh, has directed Niva Bupa Health Insurance Company Ltd to settle the complainant’s full medical bill of ₹1,33,946, along with interest at 9% per annum from the date of repudiation of claim.

The complainant, Salil Talwar, a resident of Sector 18-B, Chandigarh, submitted that he bought a health insurance policy from Max Bupa Health Insurance Company Ltd (now Niva Bupa Health Insurance Company Ltd), New Delhi, by paying a premium of ₹16,496.

On June 8, 2019, he met with an accident at the Mumbai railway station. After mild treatment at Mumbai, he was admitted to Max Hospital, Mohali, where he was treated for factures and discharged on June 13, 2019.

However, the claim for cashless treatment was denied by the insurance company. Thereafter, the insurer sent a notice to the complainant for cancellation of the policy on grounds of non-disclosure of pre-existing disease — seizure disorder, hepatitis and lipoma excision.

Sahil claimed that he filed a response, but the company cancelled the policy. As a result, he had to pay the ₹1,33,946 hospital bill out of his own pocket.

In response to his complaint, the insurance company informed the commission that during investigation, non-disclosure of hepatitis in 1999, three seizures, with last episode in 2008, and lipoma excision in 2005 were discovered.

This was never disclosed by the complainant before purchase of the policy, which was gross violation of the terms and conditions. Therefore, the cashless request was denied and the complainant was served with notice for cancellation of the policy.

However, the commission observed that the pre-existing diseases that the complainant suffered long back in 1999, 2008 and 2005 had no nexus with the treatment taken from Max Hospital, Mohali, in 2019.

“It is clear that the insurance company has not been able to connect the previous diseases/ ailments with the present diseases/ailments, for which he had taken treatment from the treating hospital. Hence, it is unsafe to hold that the company was justified in repudiating the claim of the complainant and the present consumer complaint deserves to succeed,” the commission held, directing the insurer to settle the complainant’s hospital bill and also pay ₹10,000 as compensation for causing mental agony and harassment, and another ₹10,000 as cost of litigation.