Raipur (Chhattisgarh) Consumer Commission Orders Star Health To Repay Deducted Insurance Claim With Interest

The Raipur (Chhattisgarh) District Consumer Disputes Redressal Commission bench presided by Shri Dakeshwar Prasad Sharma along with Smt. Nirupama Pradhan and Shri Anil Kumar Agnihotri as members, has held Star Health and Allied Insurance Company guilty of deficiency in service and unfair trade practice for arbitrary deduction of Rs.12000/- from a health insurance claim. The insurance company was directed to refund the deducted amount along with interest. Brief Facts Mohit Gandhi (Complainant) had bought a health insurance policy from “Star Health and Allied Insurance Company” valid from 15.12.2022 to 14.12.2023. On 22.12.2022, Mohit got admitted to Raipur Stone Clinic for treatment of a kidney stone incurring medical expenses of Rs.74,600/-. When Mohit claimed the said amount from the insurance company, they partially admitted the claim and reimbursed Rs.62,470/- deducting Rs.12,000/- in the name of “professional fees and procedure charges”, on the basis that the said expenses are not 'reasonable and necessary'. Aggrieved by this, Mohit approached the Raipur Consumer Commission asking for relief. Despite, service of notices, the Star Health and Allied Insurance Company failed to appear before the Commission and the case proceeded ex parte. Decision by the Raipur District Commission The Commission noted that while making the deductions of Rs.12000/-, the insurance company failed to mention any specific terms or conditions that could justify the said deductions. The Assessment Sheet by the Insurance Company had merely mentioned that these expenses were not reasonable and necessary but has not furnished information on what basis the aforementioned expenses were not reasonable and necessary. The Bench observed that any hospital's or treatment's professional fees and procedure charges can differ and further clarified that the Insurance Company is duty bound to communicate the exact grounds of deductions made in the insurance claim. Therefore, the deduction of Rs.12000/- made by the Star Health and Allied Insurance Company without any clear justification amounted to deficiency in services and unfair trade practices. While partly allowing the complaint, the Commission directed the Insurance Company to refund Rs.12000/- with 6% interest from the date of filing, compensation of Rs.3000/- and litigation cost of Rs.2000/-. Case Title: Mohit Gandhi vs. Star Health and Allied Insurance Company Consumer Complaint No - CC/2024/296 Click here to Read/Download the Order

Raipur (Chhattisgarh) Consumer Commission Orders Star Health To Repay Deducted Insurance Claim With Interest

Apoorva Pandita

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