Mohali Insurer Fined For Wrongful Rejection Of 45k Health Claim
Hindustan Times
Mohali The District Consumer Disputes Redressal Commission has directed ICICI Lombard General Insurance Company to reimburse a Mohali resident s medical expenses as it observed that the insurer wrongly rejected his health insurance claim by linking his Hepatit
Mohali The District Consumer Disputes Redressal Commission has directed ICICI Lombard General Insurance Company to reimburse a Mohali resident’s medical expenses as it observed that the insurer wrongly rejected his health insurance claim by linking his Hepatitis-A treatment to alleged alcohol consumption.
The commission ordered the insurer to pay ₹45,000 towards medical expenses along with 6% annual interest from July 12, 2022, the date on which the claim was repudiated. It also awarded ₹15,000 as compensation for mental harassment and litigation expenses.
Complainant Manjot Singh, a resident of Phase 9, Mohali, had purchased a health insurance policy with a sum insured of ₹10 lakh for the period from July 24, 2021, to July 23, 2022. He developed severe abdominal pain in June 2022 and underwent treatment at Government Medical College and Hospital, Sector 16, Chandigarh, and later at PGIMER where doctors diagnosed him with Hepatitis-A.
After incurring treatment expenses of about ₹45,000, Singh submitted a reimbursement claim to the insurer. However, the company rejected the claim on July 12, 2022, stating that the disease was attributable to alcohol consumption and citing a policy exclusion relating to treatment for alcoholism.
Appearing before the commission, the insurer argued that medical records showed the complainant had been advised to abstain from alcohol, supplements and gym proteins. It contended that the claim fell within policy exclusions relating to alcoholism and substance abuse.
The commission, comprising president SK Aggarwal and member Lt Col Jasbir Singh Bath, rejected the insurer’s stand. It observed that the medical records clearly showed that Singh was treated for Hepatitis-A and did not indicate that he was undergoing treatment for alcoholism or de-addiction.
The commission held that merely advising a patient to avoid alcohol could not be treated as evidence that the illness resulted from alcoholism. It termed the repudiation arbitrary, unjustified and contrary to the terms of the insurance policy.
The commission directed the insurer to make the payment within 30 days, failing which the amount would carry interest at 9% per annum until realisation.