Ghaziabad: Holding that the burden of proving a pre-existing illness lies with the insurance company, the district consumer disputes redressal commission has directed Star Health and Allied Insurance to reimburse a policyholder’s claim after finding deficiency in service.The order, passed on July 31 by commission president Anil Kumar Pundir and members R P Singh and Shailja Sachan, held that an insurance company cannot reject a health insurance claim merely on suspicion or hospital admission notes. “The grounds for rejecting an insurance claim must be solid, clear, and credible,” the commission held.The commission directed the insurer’s Vaishali branch office to pay Rs 61,582, along with 6% annual interest from the date the complaint was filed, within 30 days. It said that if the payment is not made within the deadline, the interest rate will increase to 9% per annum thereafter.The dispute arose from a complaint filed by Ghaziabad resident Praveen Kumar on Aug 1, 2022. Kumar said he purchased a family health insurance policy from Star Health and Allied Insurance on May 17, 2018. The policy, renewed in 2020, covered two adults and three children for a sum assured value of Rs 6.75 lakh and remained valid till May 16, 2021.Kumar told the commission that while the policy was in effect, his daughter underwent medical examination at Metro Hospital before being admitted to Artemis Hospital in Gurgaon for treatment. The hospital raised a bill of Rs 93,148. Kumar submitted a reimbursement claim, but the insurer rejected it, alleging that he had concealed his daughter’s pre-existing illness while purchasing the policy.Kumar’s counsel argued that the allegation was baseless and that the illness developed only during the policy period. The insurer, however, contended that the patient had been suffering from the disease for nearly four years and alleged that the complainant had submitted incorrect medical information to obtain the claim.After examining the records, the commission observed that one medical record mentioned weakness in the patient’s legs for two to three years but did not establish that she had been suffering from the disease during that period. “Mere weakness and similar symptoms cannot be used to conclude that the insured person had a specific disease like Myasthenia Gravis before the policy became effective,” the commission held.It further noted that the girl’s treating doctor had clarified in writing that the patient was healthy until two to three months before diagnosis and that symptoms of the disease had begun only two to four months earlier.While noting that the terms of an insurance policy are binding on both parties, the commission held that the insurer failed to produce any previous medical records or documentary evidence proving that the insured had the disease before the policy came into force or had deliberately concealed it. It, therefore, held that the insurer’s action amounted to deficiency in service.The commission, however, also noted that not all components of the claim were payable under the policy. It directed the insurer to reimburse expenses comprising Rs 43,898 towards hospitalisation, Rs 17,453 towards pre-hospitalisation expenses and Rs 231 towards post-hospitalisation expenses, taking the total payable amount to Rs 61,582.
