Idukki District Commission Holds Star Health And Allied Insurance Company Liable For Rejection Of Insurance Claims

The District Consumer Disputes Redressal Commission, Idukki presided by Sri. C. Sureshkumar (President) and Sri. Ampady K.S. (Member) held Star Heath and Allied Insurance Company liable for grave deficiency in service as they denied the claim of the complainant due to insufficient document. Brief facts: The complainant purchased medical insurance for his family from Star Health and Allied Insurance Company (respondent) which was valid from 12.8.2021 to 11.8.2022. Unfortunately, in May 2022 the complainant's son was admitted in hospital for Synovitis Left knee- Oligoarticular Juvenile Idiopathic arthritis. According to the policy, the complainant was entitled for cashless treatment but the respondent denied pre-authorization request for cashless treatment due to insufficient documents. After paying Rs.67,726/-, the complainant submitted the relevant documents to claim reimbursement of treatment. However, the respondent denied the claim. The complainant sent a lawyer notice on 5.10.2022 to the respondents but they did not respond. Being aggrieved, the complainant filed a complaint in the District Commission for deficiency in service and unfair trade practice against the insurance company. Contentions of Star Health and Allied Insurance Company: In response, the respondent contended that the complainant's son was diagnosed with sprain of ACL left knee due to fall from bicycle 3 months ago. However, the complainant has not submitted first consultation report and investigation documents before admitting in hospital. They further argued that due to non-availability of documents they could not ascertain duration of infirmity and thus, request for cashless treatment was rejected. Subsequently, due to absence of essential documents, the claim for reimbursement was also rejected. Upon denial of claim, the respondent had returned all the original documents to the complainant on 6.9.2022. Observation of the District commission: The commission noted that the complainant's son consulted the doctor 3 months after the fall from the bicycle on 27.02.2022, when the pain worsened. After the first consultation, the complainant's son was admitted in hospital on 27.05.2022. Later, the complainant's son was diagnosed with oligoarticular juvenile idiopathic arthritis that was triggered by the fall from bicycle. Thus, the injury has taken place during the subsistence of policy. The commission observed that the complainant submitted all the required information and medical records for pre authorization of cashless treatment initially and subsequently for reimbursement of treatment expenses. Therefore, the respondent was held liable for repudiation of claim. Consequently, the District Commission directed the respondent to pay Rs.67,726/-with 12% interest. Further, they were directed to pay Rs.25,000/- with 12% interest as compensation along with Rs. 5000 as litigation costs. Case title: Lalu Joseph vs The Authorised Signatory, Claims Department, Star Health and Allied Insurance Company Ltd Case No: CC NO.183/2022 Date of Pronouncement: 29.11.2024 Click Here To Read/Download The Order

Idukki District Commission Holds Star Health And Allied Insurance Company Liable For Rejection Of Insurance Claims

Amrisha Kumari

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