E-Paper
Health insurance company directed to pay ₹20k compensation
The private health insurance company was asked to pay a composite compensation of ₹20,000 to the complainant within 30 days from the date of receipt of the copy of the order
: The District Consumer Forum Redressal Commission has directed a private health insurance company to pay a compensation of ₹20,000 to a complainant in Ludhiana for the rejection of claim settlement.
The Consumer Dispute Redressal Commission comprising of President Sanjeev Batra, member Jaswinder Singh, and Monika Bhagat directed the Star Health & Allied Insurance Company Limited to pay a composite compensation of ₹20,000 to the complainant within 30 days from the date of receipt of the copy of the order.
Sarabjeet Kaur, 58, resident of Basant Avenue, Dugri filed a complaint on January 14, 2022, under section 35 of the Consumer Protection Act, 2020, seeking approval of the cashless claim for her knee surgery and compensation of ₹2,00,000 for mental pain, agony, harassment, and litigation expenses.
She stated that she obtained a cashless policy ‘Family Health Optima Insurance plan’ for a sum insured of ₹5,00,000 from Star Health & Allied Insurance Company on payment of a premium of ₹25,165 for the period from September 18, 2019 to September 17, 2020.
The complainant got the policy renewed from September 18, 2020 to September 17, 2021 for a premium of ₹25,165 and the limit of coverage insurance was enhanced to ₹625,000.Later, the limit of coverage insurance was increased to ₹675,000.
Sarabjeet further stated that she had to undergo surgery for knee replacement. She filed a claim for a medical treatment which was initiated by the opposite parties. On the same day, the corporate staff of the hospital sent details of the disease and treatment to the opposite parties but they denied the request for approval of cashless treatment on November 24, 2021.
The opposite parties alleged that on scrutiny of the cashless claim authorisation letter received by them, it is observed from the hospital record that the complainant had the above said disease which is a long-standing ailment and they were not able to ascertain the duration of the disease based on the documents/details submitted by the complainant and the same required further evaluation. Hence, the cashless authorization was rejected.
The opposite parties further alleged that as they did not approve of the cashless facility, the complainant did not get admitted and treated in DMC Hospital, but subsequently, she was hospitalised at Orison Super Specialty Hospital, for the diagnosis and treatment of Bilateral OA Knee.
Star Health & Allied Insurance Company Limited stated that insured (complainant) submitted claim documents for reimbursement of medical expenses and on the basis of the submitted documents, an amount of ₹3,41,491 against the claimed amount of ₹3,75,512 was settled to the insured through NEFT transaction.
The forum reported that the complainant held the policy in question and was advised by Dr. Rajnish Garg, head of the department of orthopaedics at Dayanand Medical College and Hospital in Ludhiana to undergo knee replacement surgery during the policy’s second renewal period on November 11, 2021.
After the waiting period of 24 consecutive months had elapsed since the policy’s inception, the complainant submitted a pre-authorisation request for approval of cashless treatment along with a complete set of documents. However, the opposite parties declined the cashless authorisation, the forum added.
