Health insurance firm told to pay Rs 1.68L claim
The District Consumer Disputes Redressal Commission, Chandigarh, has directed an insurance company to pay compensation of Rs 20,000 to a city resident for denying his medical claim. It has also directed the company to pay claim amount of Rs 1.68 lakh to the complainant along with 9 per cent interest per annum from the date of refusal of the claim.
A resident of Sector 21-C, Chandigarh, in a complaint filed before the commission said that he and his wife had purchased a health insurance from M/s Niva Bupa Health Insurance Company. The policy was valid till 2026 on premium of Rs 1,65,926 with sum insured of Rs 15 lakh.
On October 24, 2023, the complainant was admitted at Shuddhi Ayurveda Panchkarma Hospital, Devinagar. He was discharged on November 7, 2023, after remaining in the hospital for 15 days. The total amount charged by the hospital for the entire treatment was Rs 1.68 lakh. The hospital also issued a certificate of treatment.
He raised the claim for Rs 1.68 lakh but the insurance company rejected it on the ground that the patient was admitted for diagnostic and evaluation purpose and so the claim was not payable as per policy.
He said that as per clause 3.2 of the policy Ayush treatment was covered if the insured was admitted for 24 hours or more. It is on record that he remained admitted in the Ayush hospital for 15 days.
On the other hand the insurance company justified the rejection and said that the insured person was admitted primarily for investigation and evaluation purposes.
After hearing the arguments the commission said that the certificate issued by the treating hospital clearly indicated that the insured patient needed proper hospitalisation as he was in severe pain. “In view of this, the insurance company is directed to pay Rs 1.68 lakh to the complainant(s) along with interest, Rs 20,000 compensation and Rs 10,000 as cost of litigation,” the order said.
