Denied Insurance Childs Typhoid Treatment Father Rs 60000 Payout

A Haryana consumer commission directed Star Health Insurance to reimburse Rs 54,286 spent on a child’s hospitalisation for typhoid fever, observing that health insurance policies are obtained by consumers with the legitimate expectation that genuine hospitalisation expenses would be indemnified in accordance with the policy terms.

Noting that the complainant has been harassed by the opposite parties unnecessarily for a long time, a bench of president Charanjit Singh, members Nidhi Verma and V P S Saini also awarded Rs 7,500 as compensation and Rs 5,500 as litigation expenses.

“It is also noteworthy that health insurance policies are obtained by consumers with the legitimate expectation that genuine hospitalisation expenses would be indemnified in accordance with the policy terms. When a claim arising from an admitted hospitalisation is repudiated on conjectures and surmises rather than on concrete evidence, it amounts to a deficiency in service and causes unnecessary mental agony and financial hardship to the insured,” the commission said on June 24.

The order noted that the opposite parties have failed to establish which particular document was not supplied by the complainant, nor have they placed on record any correspondence calling upon the complainant to furnish any specific information which remained uncompiled. It added that once the complainant submitted the discharge summary, treatment record, bills and claim form, the burden shifted to the insurer to prove violation of the policy condition.

Underscoring that a claim cannot be rejected on vague and indefinite grounds, the bench said that the repudiation must be supported by cogent material and valid reasons, but in the present case, the insurance company have failed to demonstrate any deliberate suppression of facts, fraud, misrepresentation or violation of any exclusion clause under the policy.

The complainant was approached by an agent of the opposite parties, who assured that the insurance services provided by the insurance company are the best in their field. Thereafter, as per the assurance, the complainant had availed one Family Health Optima Insurance plan in the year 2018, and the complainant renewed the policy for a sum of Rs 5 Lakh, and a bonus was also given to the policyholders. In respect of that, the requisite premium was paid by the complainant to the opposite parties.

On August 22, 2023, the complainant’s minor son felt ill with high grade fever, as such the complainant immediately visited Cherish Children Hospital Tarn Taran, for the treatment of his minor son and as per the advice given by the doctor, the minor was got admitted on the same day and he was diagnosed with Enteric Fever C Sepsis and he remained under the observation of the doctors for about three days and he got discharged on August 25, 2023.

The complainant, before getting his son admitted to the Hospital, approached the representatives of the opposite parties as the minor son of the complainant was medically insured by them, and on the instruction of the opposite parties, the complainant provided all the particulars as well as details regarding his health policy.

Despite the due intimation given to the opposite parties, no approval was granted to continue the treatment of the complainant cashless. As it was a matter of grave emergency, the complainant’s son needed medical treatment immediately to save his life, and thereafter, he himself paid all the medical expenses from his own pocket. The complainant had paid a sum of Rs 54,286 for the treatment of his son, which includes hospital expenses, medical expenses, consultation fee, etc.

After the attempt to reimburse the amount, the complainant was assured by the insurance company that the reimbursement regarding the claim would be made in a couple of weeks. After a couple of months, instead of reimbursing the amount, the opposite party required the documents of the treatment record, etc. However, the complainant received a letter in August 2023, which declined the claim, according to the complainant, by giving vague reasons that various discrepancies in the submission of the documents.

The insurance company submitted a written statement, arguing that the complaint is vague, improper, and illegal, and against the facts, hence the same is not maintainable in the eyes of law and the same deserves to be dismissed.

It was argued that the opposite party had rendered all possible services to the complainant, and there was/is no deficiency in services on the part of the insurance company; as such, the complaint deserves to be dismissed.

Jagriti Rai works with The Indian Express, where she writes from the vital intersection of law, gender, and society. Working on a dedicated legal desk, she focuses on translating complex legal frameworks into relatable narratives, exploring how the judiciary and legislative shifts empower and shape the consciousness of citizens in their daily lives. Expertise Socio-Legal Specialization: Jagriti brings a critical, human-centric perspective to modern social debates. Her work focuses on how legal developments impact gender rights, marginalized communities, and individual liberties. Diverse Editorial Background: With over 4 years of experience in digital and mainstream media, she has developed a versatile reporting style. Her previous tenures at high-traffic platforms like The Lallantop and Dainik Bhaskar provided her with deep insights into the information needs of a diverse Indian audience. Academic Foundations: Post-Graduate in Journalism from the Indian Institute of Mass Communication (IIMC), India’s premier media training institute. Master of Arts in Ancient History from Banaras Hindu University (BHU), providing her with the historical and cultural context necessary to analyze long-standing social structures and legal evolutions. ... Read More