Consequential Diagnosis To Treatment Must Be Reimbursed, Thane District Commission Holds Star Health And Allied Co. Liable

Brief Facts of the Case:

In 2013, Mr. Diliprao D. Mohite (“Complainant”), a resident of Kisan Nagar in Wagle Estate, Thane, obtained a medical insurance policy from Star Health and Allied Insurance Co. Ltd. (Insurance Company). This policy provided coverage for up to Rs. 5.5 lakh and required an annual premium payment of Rs. 23,976.

Subsequently, the Complainant experienced severe heart pain, leading to his admission to Jupiter Lifeline Hospital Ltd. (“Hospital”) in Thane. While in the hospital, he duly informed the insurance company about his medical condition and filed a claim for reimbursement of his medical expenses. The hospital received the initial claim amount. However, the complainant realized that the remaining expenses incurred during his treatment were not covered by the insurance policy. In response, he approached the insurance company to claim the outstanding amount.

The insurance company contended that their repudiation of the complainant’s was justified, primarily citing the policy's exclusion clause which explicitly excluded expenses incurred primarily for diagnostic purposes, X-ray examinations, or laboratory examinations that were not consistent with or incidental to the diagnosis and treatment of an ailment. It further contended that the Complainant’s hospitalization was primarily diagnostic and, therefore, the exclusion clause was applicable. On the other hand, the hospital disassociated itself from any wrongdoing and emphasized that there was no direct relationship between its facility and the insurance company.

Observations by the Commission:

The District Commission noted that the complainant’s admission to the hospital was not solely for diagnostic purposes but was necessitated by severe heart pain, which was subsequently diagnosed as Paroxysmal AF with CVA. The medical records and discharge summary indicated that the complainant’s hospitalization was indeed for treatment, as supported by the diagnosis and the subsequent medical decisions.

In light of this critical observation, the District Commission ruled that the exclusion clause, which excluded diagnostic expenses unrelated to treatment, did not apply to the complainant’s situation. It was determined that the complainant’s hospitalization was not merely for diagnostic purposes, as the insurance company had asserted, but was medically warranted for the treatment of his heart condition.

Consequently, the District Commission found that the insurance company had committed a deficiency in service by erroneously repudiating the complainant’s claim. The District Commission directed the insurance company to pay the complainant an amount of Rs. 33,500 at a rate of 8 per cent per annum. It was also directed to pay the complainant compensation of Rs. 15,000 for the mental agony endured and Rs. 5,000 towards the costs of the complaint.

Case: Diliprao D Mohite vs. M/s Star Health and Allied Insurance co Ltd

Case No.: CC/558/2017

Advocate for the complainant: Adv Nanabhau Varkhate & Adv Mahesh Solanke

Advocate for the Respondent: Adv Balaji Umate

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