Do Not Deny Insurance Claim For Brief Home Visit During Hospitalization, Ludhiana Commission Holds Aditya Birla Health Insurance Co. Liable

Brief Facts:

Mr. Rajkaran Singh (“Complainant”), a 27-year-old resident of Kalakh Kalan village in Jagraon, Punjab, had purchased a Mediclaim policy from Aditya Birla Health Insurance Co. Limited (“Insurance Company”), which was valid from July 31, 2019, to July 30, 2020. During the policy period, the Complainant was admitted to Sood Hospital in Ahmedgarh on September 22, 2019, due to health issues. His medical diagnosis included fever, a reduced platelet count, dengue fever, serology, and post-viral pneumonia. Medical expenses amounting to Rs 69,915 were incurred during his hospitalization.

After his hospitalization, the Complainant filed a claim with the Insurance Company for the medical expenses incurred. However, the insurance company rejected his claim, asserting that the Complainant had occasionally left the hospital to visit his home for a few hours during his hospitalization. Additionally, the insurance company pointed to discrepancies in the hospitalization dates and raised doubts about the authenticity of the hospitalization records. Aggrieved, the Complainant filed a consumer complaint in the District Consumer Disputes Redressal Commission, Ludhiana (“District Commission”).

The Complainant contended that he had purchased the Mediclaim policy in question based on the assurances and representations made by the insurance company's representatives. He argued that during the policy's validity period, he was admitted to Sood Hospital in Ahmedgarh due to various health issues, as diagnosed by the attending physicians. The Complainant claimed that he did not make any false declarations or fraudulent statements in his claim, and he had not violated any terms and conditions of the policy. He contended that the rejection of his claim by the insurance company was unjust and without merit, characterizing it as an unfair trade practice and a deficiency in service on the part of the insurance company.

The insurance company argued that the Complainant’s claim was rightfully repudiated based on the terms and conditions of the policy. They contended that the Complainant had admitted to leaving the hospital for brief periods during his hospitalization, and this was a violation of the policy terms. The insurance company referred to discrepancies in the hospitalization records and alleged that there were inconsistencies in the dates and details provided. They asserted that the Complainant was obligated to disclose all material facts related to his health, and his failure to do so amounted to a fraudulent claim.

Observations by the Commission:

The District Commission found that even if the Complainant had briefly visited his home during the last three days of his hospitalization, this did not justify the rejection of his claim. The District Commission emphasized that the claim related to the Complainant’s genuine health condition, and any departure from the hospital during his admission did not constitute a fraudulent claim or a breach of policy terms justifying repudiation.

The District Commission, after reviewing the discharge summary provided by the treating doctors, found no substantial evidence to suggest that the hospitalization records were falsified. The discharge summary contained a chronological treatment record, confirming the Complainant’s hospitalization and the treatments administered. The District Commission acknowledged the insurance company's assertion that policyholders have an obligation to disclose all material facts related to their health. However, in this case, it was determined that the Complainant’s claim was not fraudulent, and he had not concealed material facts that would have justified the rejection of his claim.

The District Commission partially allowed the complaint, directing the Insurance Company to settle and reimburse his claim of Rs. 69,915 strictly in accordance with the terms and conditions of the policy within 30 days from the date of receiving a copy of the order. In the event of non-compliance, the insurance company would be liable to pay interest at a rate of 8% per annum on the settled amount from the date of the order until the actual payment. Additionally, the District Commission ordered the insurance company to pay the Complainant a composite cost of Rs 10,000 within 30 days from the date of receiving a copy of the order.

Case: Rajkaran Singh vs Aditya Birla Health Insurance Co. Ltd.

Case No.: CC/20/81

Advocate for the Appellant: Ripon Chadha Adv.

Advocate for the Respondent: Ashok Kumar adv

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