The Ernakulam district consumer disputes redressal commission in Kochi has ordered Aditya Birla Health Insurance Company to compensate a policyholder, Joy Paulose, for wrongfully denying a legitimate claim for accident treatment expenses. The insurance company had cited ‘non-disclosure of pre-existing conditions’ as the reason for denying the claim. However, the commission found this reasoning to be unlawful and against the principles of the insurance contract and Consumer Protection Act.
Paulose had taken out an insurance policy on January 17, 2024, and was involved in an accident on February 2, 2024, where he fell 10 feet at his residence, resulting in serious injuries, including rib fractures, pneumothorax, and a hand fracture. He was treated at a private hospital in Kolenchery and incurred medical expenses of Rs 81,042. Despite seeking cashless treatment under the policy, the insurance company rejected the request and later denied the claim, alleging that Paulose had not disclosed pre-existing ailments.
The commission, comprising Chairman D B Binu and members V Ramachandran and T N Srividya, ruled in favor of Paulose, stating that the insurance company’s action was unacceptable and a clear case of deficiency in service and unfair trade practice. The commission observed that it is the joint responsibility of the insurance sector and the legal system to protect the legitimate rights of consumers.
As a result, the commission ordered the insurance company to pay the claim amount of Rs 81,042 with an annual interest of 12%, as well as compensation of Rs 30,000 and court costs of Rs 5,000, totaling Rs 116,042. The payment must be made within 45 days. The commission’s decision highlights the importance of protecting consumer rights and ensuring that insurance companies do not unfairly deny legitimate claims. The case serves as a reminder to insurance companies to act in accordance with the principles of the insurance contract and Consumer Protection Act.