The District Consumer Disputes Redressal Commission-II in Chandigarh has ruled in favor of a policyholder, Tejinder Singh, who was denied a cashless medical claim for his wife’s dengue treatment by Care Health Insurance Ltd. The commission ordered the insurer to reimburse Rs 60,000 along with 9% interest and awarded an additional Rs 10,000 as compensation for harassment and litigation expenses. Singh had purchased a group health insurance policy covering himself, his wife, and their son, and had renewed it multiple times. However, when his wife was admitted to a hospital in Panchkula with dengue in November 2022, the insurer rejected the claim, citing non-disclosure of pre-existing conditions, specifically rheumatoid arthritis.
The commission found this rejection to be arbitrary and lacking merit, as the medical records clearly indicated that the treatment was for dengue, a condition unrelated to any alleged pre-existing ailments. The order emphasized that insurance companies cannot cite medical history that has no relevance to the actual treatment sought to deny legitimate claims. This decision is based on legal precedents, including a Punjab and Haryana high court judgment, which stated that insurers who choose not to conduct medical examinations before issuing policies cannot later deny claims based on alleged non-disclosure of health conditions.
The commission found deficiency in service on the part of the health insurance company and held that the purpose of obtaining an insurance policy is not for luxury but to cover unforeseen eventuality. With rising healthcare costs, health insurance is becoming a necessity for families. However, many policyholders often find themselves in battles with insurers over claim denials, usually citing fine-print clauses or technicalities. This case underlines the need for clearer communication from insurers and fair claim practices. It also signals that consumers have legal recourse and can challenge claim denials successfully through consumer courts.
The ruling highlights the growing concerns over insurance claim denials and the need for insurance companies to be more transparent and fair in their claim practices. It also emphasizes the importance of consumer courts in protecting the rights of policyholders and ensuring that insurance companies are held accountable for their actions. The decision is a significant victory for policyholders and a reminder that they have legal recourse if their claims are denied unfairly. Overall, the ruling promotes fairness and transparency in the insurance industry and protects the interests of policyholders.