The District Consumer Disputes Redressal Commission has penalised a health insurance company for rejecting the medical claim of a city-based woman who was hospitalised due to fever and shortness of breath in October 2022.
The commission directed the company to pay ₹24,077 to the complainant, along with interest at 9% per annum from November 22, 2022, onwards. Besides, it will pay ₹15,000 as compensation for causing mental agony, harassment and cost of litigation.
Complainant Bhawna Gupta had filed a case against Star Health and Allied Insurance Company Limited, Chandigarh, and Gupta Nursing Home, Ambala. Gupta said she had been getting the health insurance policy from the company for the last six years and it was valid from July 2022 to July 2023 on payment of a premium of ₹15,777.
The complainant alleged that the company never supplied the policy terms and conditions to her. In October 2022, due to fever and sudden shortness of breath, she was hospitalised at Gupta Nursing Home, Naraingarh, and spent ₹27,803 on her treatment.
However, in November, the company repudiated the claim on the grounds that the investigation and treatment of the insured patient were not transparently evident. Before the commission, the insurance company resisting the complaint stated that the documents were tampered with, and as per the policy, if there was any misrepresentation by the insured person or any other person acting on his behalf, the company was not liable to make any payment.
{{/usCountry}}However, in November, the company repudiated the claim on the grounds that the investigation and treatment of the insured patient were not transparently evident. Before the commission, the insurance company resisting the complaint stated that the documents were tampered with, and as per the policy, if there was any misrepresentation by the insured person or any other person acting on his behalf, the company was not liable to make any payment.
{{/usCountry}}The case was proceeded against the hospital ex parte.
The commission observed: “No such investigation report has been proved or produced on record by the company in order to prove that the complainant has misrepresented any fact qua her treatment. Hence, it is unsafe to hold that the insurance company was justified in repudiating the claim of the complainant and the said act certainly amounts to deficiency in service and unfair trade practice on its part.”