Noida: District Consumer Disputes Redressal Commission Commission has directed Iffco Tokio General Insurance Company to pay Rs 62,930 with 6% interest to a policyholder whose claim was rejected. It also ordered the insurer to pay the claimant Rs 4,000 towards litigation cost and mental agony.Greater Noida resident Ajay Kumar filed a complaint on Feb 7, 2024, alleging that the insurer rejected his medical claim on the ground that there was no need for hospital admission and outpatient treatment could have been obtained instead. Kumar purchased the named Swasthya Kavach Floater policy in 2017 with a sum assured value of Rs 5 lakh. It was renewed annually and was last renewed on Dec 13, 2022, after paying a premium of Rs 14,830.The policy covered his wife, son and daughter.On Oct 30, 2023, Kumar was admitted to the emergency department at Kailash Hospital. According to the doctor’s report, Kumar was advised to be admitted immediately and the hospital sent an approval request with an estimated cost of Rs 56,000.The query letter and doctor’s certificate were handed over to the insurer, but they refused the cashless treatment request, and Kumar had to pay the hospital bills out of pocket. Kumar said that he learnt from the insurance company officials that his claim was rejected as they considered his illness to be not so severe that it required hospitalisation.“Kailash Hospital sent a letter requesting reconsideration, requesting approval for the cashless claim, but the respondent ignored this request. My claim was arbitrarily rejected, which is nothing but deficiency in service,” Kumar said.The insurer’s counsel submitted a counterclaim refuting the claims, stating that the insurer examined the documents and found that the patient was admitted for a condition that could have been treated in the OPD.“Hospitalisation was not required, and therefore, the cashless treatment facility was denied. A claim cannot be approved if a person fails to disclose pre-existing medical conditions, as concealing information results in the policy being void. In this case, the complainant did not disclose his illness,” the counsel said.After examining documents provided by both parties, the commission noted, “The doctor only will determine whether the complainant’s illness will be treated in an outpatient setting or in hospital. The patient was admitted, considering abdominal pain, high fever and vomiting, as evidenced by the doctor’s discharge summary. How did the defendant conclude that the illness could only be treated in an outpatient setting?”It declared the insurer’s claims an act of deficiency in service and ruled in the complainant’s favour.
