Surat: Surat District Consumer Disputes Redressal Commission (Additional) has directed a private insurance company to pay a policyholder Rs 73,000 towards hospitalisation expenses, observing that a certificate issued by a homeopathic doctor could not substantiate the rejection of the claim when the treating hospital had no homeopathy facility.The commission also held that the insurer, Aditya Birla Health Insurance Company Ltd, had failed to provide sufficient evidence to establish the other grounds cited for rejecting the claim.However, the commission noted that the hospital where the policyholder was treated did not have a homeopathy facility, raising questions about the validity of the certificate.According to the complaint, Nishant Kothari had purchased a health insurance policy covering the period from May 14, 2018, to May 13, 2019. During the coverage period, he was admitted to Unique Hospital from September 2 to 6, 2018, for treatment of abdominal pain. The hospitalisation and treatment cost Rs 73,000.Kothari submitted a claim with the necessary documents, but the insurer rejected it, citing non-disclosure of a pre-existing disease, the waiting period and permanent exclusion clauses. He subsequently approached the commission, seeking reimbursement and compensation for mental agony and harassment.Examining the medical records, the commission observed that the certificate relied upon by the insurer had been issued by a homeopath, while the discharge summary showed that Kothari had been treated at a hospital without a homeopathy facility.The commission also found that the proposal form did not clearly establish whether Kothari had specifically been asked about the illness for which he later received treatment. The insurer had failed to produce sufficient evidence to prove that he had concealed a pre-existing disease or that the illness was covered by the applicable waiting period under the policy.The insurer was also directed to pay Rs 3,000 as compensation for mental agony and harassment and Rs 2,000 towards litigation expenses.
