Mohali: Claim rejection invalid; insurer to foot ₹74k hospital bill, rules panel

In its October 12 order, the commission’s president, SK Aggarwal, and member Paramjeet Kaur partly allowed the complaint filed by Sneh Lata, wife of Prem Prakash, who resides in Patiala Complex, Dera Bassi

A consumer commission directed Care Health Insurance to reimburse a Dera Bassi woman ₹74,000 for hospital treatment and ambulance charges after holding that the insurer wrongly rejected her claim by invoking a 24-month waiting period for spinal disorders despite her account of an accidental fall.

The insurer maintained that the claim concerned disc sequestration and a chronic spinal disorder covered by the waiting-period clause. It relied on a second medical opinion to support its decision. (HT File)

The commission also ordered the insurer to pay 6% annual interest on the amount from October 1, 2022, the date of repudiation, and ₹25,000 as compensation for mental agony and harassment as well as litigation expenses.

In its October 12 order, the commission’s president, SK Aggarwal, and member Paramjeet Kaur partly allowed the complaint filed by Sneh Lata, wife of Prem Prakash, who resides in Patiala Complex, Dera Bassi.

Lata had purchased a health insurance policy from Care Health Insurance for May 28, 2022, to May 27, 2023, after holding earlier policies with Cigna TTK Pro Health Insurance.

According to the complaint, she developed severe pain after falling from her bed on September 28, 2022, and was taken by ambulance to Alchemist Hospital. An MRI of her lumbosacral spine showed disc-related abnormalities. The hospital sought cashless treatment authorisation, which the insurer initially approved for ₹33,000 before withdrawing it on the ground that spinal disorders carried a 24-month waiting period.

Lata was discharged against medical advice on October 3, 2022, after incurring medical expenses of ₹72,375. She also paid ₹2,000 for the ambulance. She argued that the treatment followed an accident and that the insurer should have considered her previous insurance coverage while calculating the waiting period.

The insurer maintained that the claim concerned disc sequestration and a chronic spinal disorder covered by the waiting-period clause. It relied on a second medical opinion to support its decision.

The commission noted that the policy itself exempted spinal conditions arising from accidents from the waiting-period restriction. It said the insurer had not established that Lata’s hospitalisation was unrelated to her fall. It also observed that the company had failed to properly account for her earlier continuous insurance coverage under portability provisions.

The commission held that the insurer’s subsequent rejection, after initially approving cashless treatment, amounted to deficiency in service.

It directed the company to pay the medical and ambulance expenses with interest and ₹25,000 in compensation and litigation costs. The order does not specify a separate amount for each of the two components covered by the ₹25,000 award.