Terming as whimsical the reasons given by a health insurance company to deny claims, Dakshina Kannada District Consumer Disputes Redressal Forum recently directed it to pay compensation to two complainants.
Vijaya M (38) of Ashoknagar obtained a ‘Medi Classic Individual’ policy (valid from March 2011 to 2012) from Star Health and Allied Insurance Company Limited for herself and her daughter Madhushree (15). In May 2011, Madhushree was admitted to Adarsha Hospital in Udupi and underwent treatment for left temporal cavernoma. After Madhushree was discharged on June 1 that year, Vijaya filed a claim seeking reimbursement of the medical bill of `89,873.
However, she received no response and decided to file a complaint with the Consumer Form, seeking the same amount with 12 per cent interest. Deposing before the Forum, officials of the insurance company said Madhushree had undergone treatment for left temporal vavernous angioma with seizures, which it claimed was a congenital internal disease, and thus, came under its exclusion clauses. On scrutiny of documents of the case, the Consumer Forum found that an eminent neurosurgeon, Dr A Raja, who treated Madhushree, had confirmed the ailment as not being congenital. The disease was detected during a C T scan. Observing that Star Health and Allied Insurance Company Limited had not submitted any material to rebut Raja’s evidence, Consumer Forum president Asha Shetty declared it had resorted to unfair trade practices. It directed to honour reimburse Vijaya’s full claim, along with 12 per cent interest till date of payment. The firm was asked to pay `2,000 as litigation expenses within 30 days.