Rewari District Commission Holds Aditya Birla Health Insurance Co. Liable For Wrongful Repudiation Of Claim Arising From Dengue Fever

Brief Facts:

Navin Kumar (“Complainant”) purchased a medical insurance policy from Aditya Birla Health Insurance Company Limited (“Insurance Company”). During the sustenance of the said policy, the Complainant was hospitalized at City Heart Clinic and Medical Centre, Rewari (“Hospital”) for Dengue fever with Thrombocytopenia treatment. He incurred expenses totalling Rs. 31,627/-. However, the Insurance Company failed to reimburse his medical treatment expenses. The Complainant received a repudiation letter from the Insurance Company, stating unsubstantial reasons for the rejection of his claim. Feeling aggrieved, the Complainant approached the District Consumer Disputes Redressal Commission, Rewari, Haryana (“District Commission”) and filed a consumer complaint against the Insurance Company.

In response, the Insurance Company contended that the repudiation of the claim was justified due to various discrepancies found in the Complainant's medical treatment record.

Observations by the District Commission:

The District Commission held that the Insurance Company acted arbitrarily and unlawfully by unjustly repudiating the genuine claim of the Complainant. It noted that it was undisputed that the Complainant was hospitalized at the Hospital during the validity of the insurance policy. Additionally, it was established that before his hospitalization, the Complainant visited the Hospital as an OPD patient, where he tested positive for Dengue.

Despite these clear circumstances, the District Commission noted that the repudiation letter failed to provide any specific reasoning for the denial of the medical reimbursement claim. The letter merely cited vague discrepancies and lapses without elaboration, depriving the Complainant of the opportunity to address these concerns. It held that the principle of natural justice demands transparency and fairness, which the Insurance Company neglected to adhere to by not seeking an explanation from the Complainant regarding the alleged discrepancies in the medical treatment record.

Furthermore, the District Commission held that there was no evidence to suggest that the Insurance Company investigated to verify the authenticity of the Complainant's hospitalization and medical treatment. Therefore, it held the Insurance Company liable for deficiency in services.

Consequently, the District Commission directed the Insurance Company to reimburse the Complainant the sum of Rs. 31,627 /- for medical treatment expenses. Additionally, it ordered the payment of interest at a rate of 9% per annum with yearly rests from the date of filing the complaint until the expiration of 45 days from its ruling. The District Commission also directed the Insurance Company to pay a compensation of Rs. 20,000/- to the Complainant for mental agony and harassment, along with Rs. 11,000/- as litigation expenses incurred by him.

Case Title: Navin Kumar vs Aditya Birla Health Insurance Company Limited and Ors.

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