Noida: The district consumer commission has ordered Star Health Insurance to settle a claim of medical insurance worth Rs 11,000 with interest calculated at 6% per annum in favour of the policyholder, while clarifying that the line of treatment is to be decided by a qualified medical practitioner and rejecting the claim because the treatment assumed by the insurance company amounted to a deficiency in services.Commission president Anil Kumar Pundir and member Anju Sharma on Thursday ruled that the amount, along with interest calculated from the date of filing of the complaint in Nov 2024 till final payment is made, should be given within 30 days of the judgement. The commission also directed payment of an additional Rs 2,000 towards litigation costs.The consumer commission has repeatedly ruled that insurance claims cannot be rejected based on the insurer’s presumed line of treatment—only a doctor can decide that. Earlier this year, the commission directed Iffco Tokyo General Insurance to pay Rs 62,930 (complaint filed Feb 2024 by Ajay Kumar of Greater Noida) and Cholamandalam General Insurance to pay Rs 60,000 (complaint filed Jan 2021 by Girish Sharma of Noida).The present matter is linked to a complaint filed by Dadri resident Manoj Kumar Nagar on Nov 27, 2024, seeking direction to Star Health and Allied Insurance Company to settle a hospital bill of Rs 11,000 that he had to pay from his pocket despite being covered by a mediclaim with a sum insured value of Rs 5 lakh.Nagar purchased a health insurance policy in 2019 for Rs 19,675, covering himself, his wife, and his children. He renewed it annually, with the last valid period from March 8, 2024, to March 7, 2025. During this period, his daughter Ekta Nagar fell ill and was admitted to Naveen Hospital in Dadri from Sept 24 to Sept 26, 2024. After her discharge, Nagar submitted the medical reports and bills, but the insurance company rejected the claim, arguing that the patient could have been treated without hospitalisation.On being served with a notice, the insurance company submitted a counterclaim, refuting the complainant’s allegations. Counsel for the opposite party said that the complainant did not follow the treatment requirements provided under the IRDA Regulations 2002 before filing the complaint. Admitting that Nagar had purchased a policy for a sum insured of Rs 5 lakh, which covered him, his wife Pravesh Devi, and children Ekta and Deepanshu, the opposite party said that the proposer was explained the terms and conditions before the policy was issued.“The complainant did not object to the terms and conditions of the free look period. Later, a claim was filed on behalf of Ekta, stating that she was admitted to Naveen Hospital, Dadri, on Sept 24, 2024, with complaints of high fever, body aches, headaches and stomach pains. Upon review of the medical documents accompanying the claim, it was found that Ekta was diagnosed with a high fever, but her test results were normal. According to the medical documents accompanying Ekta’s claim, she did not require hospitalisation for treatment, and therefore, the claim was correctly rejected under clause 3.6 of the exclusion,” the counsel said.The commission observed that the opposing insurance company rejected the treatment claim primarily because Ekta was diagnosed with a high fever, her test results were normal, and she did not require hospitalisation for treatment.“Only the doctor treating the patient can decide whether it is necessary to treat the patient by admitting her or not. The insurance company cannot reject the claim as per the exclusion clause number 3.6 on the ground that the insured was not required to be admitted to the hospital and get treatment,” the commission held.
