Private health insurance firm ordered to pay Rs 1.88 lakh for denying Covid treatment claim to Kartarpur resident
Terming rejection as deficiency in service, the commission sets aside repudiation letter
Coming down heavily on a private health insurer for arbitrarily rejecting a Covid19 treatment claim, the District Consumer Disputes Redressal Commission has directed Max Bupa health insurance company to reimburse over Rs 1.88 lakh to a woman policyholder, terming the repudiation unjustified and based merely on suspicion. The commission presided by Dr Harveen Bhardwaj and member Jyotsna, ordered the company to pay Rs 1,65,630 spent on treatment, Rs 15,000 as compensation for mental harassment and Rs 8,000 towards litigation expenses to Komal, a resident of Kartarpur. The insurer was directed to comply with the order within 45 days.
According to the complaint, Komal had purchased a health insurance policy from the company on September 25, 2021, after paying an annual premium of Rs 7,307. During the policy period, she developed fever, cough and breathing difficulty while visiting relatives in Zirakpur on January 1, 2022. Following medical advice, she underwent a Covid test and was later admitted to a private hospital in Zirakpur on January 3 after testing positive.
She remained hospitalised in the Covid ICU until January 8 and incurred treatment expenses amounting to Rs 1.65 lakh. After recovering, she submitted a reimbursement claim with the insurer.
However, the company rejected the claim, alleging that she had failed to cooperate with its investigation and had not submitted necessary hospitalisation documents.
During the proceedings, the commission examined the discharge summary, Covid test report and treatment bills submitted by the complainant. It also noted that the insurer itself had placed several hospital documents on record, contradicting its claim that the records were not available.
The commission further observed that the complainant had written to the hospital authorising it to share her medical records with the insurer, thereby fulfilling the policy condition requiring cooperation during investigation.
Rejecting the insurer’s defence, the commission held that there was no evidence to prove that the complainant had deliberately withheld documents or obstructed the investigation. It noted that the repudiation was based on inconclusive findings rather than concrete proof.
Terming the rejection of the claim as deficiency in service, the commission set aside the repudiation letter and ordered the insurer to reimburse the treatment expenses along with compensation and litigation costs.
