Ernakulam District Commission Holds Aditya Birla Health Insurance Company Liable For Deficiency In Service

Brief Facts of the Case

The complainant had a health insurance policy from the Aditya Birla Insurance Company. The Complainant's daughter got admitted to a hospital for Acute Gastritis, hence the complainant claimed the insurance from the insurance company which was rejected without providing reasons, and no official communication followed. Believing the policy covered all hospitalization expenses, the complainant issued a notice upon rejection but received no response. The unpaid claim constituted a deficiency in service by the insurance company.

Contentions of the Opposite Party

The insurance company contended that the complainant's claim was rejected due to the policy's stipulation of a 24-month waiting period for medical or surgical treatment of illnesses and their complications, including gastritis. Since 24 months had not passed from the coverage start date, the claim was deemed non-payable per the policy conditions. The rejection was communicated to the complainant in alignment with the policy's terms, conditions, exclusions, and limitations, and these provisions bind any compensation.

Observations by the Commission

The commission observed that the treatment for acute gastritis was performed, and according to the policy, the patient should be covered; however, the insurance claim was denied because the minimum two-year period from the policy's start date had not elapsed. The commission stated that it is unrealistic to predict future illnesses, especially in the case of a child and held that since there was no evidence of existing ailments at the time of policy subscription, the insurance company was obligated to provide coverage for the child who received treatment after obtaining the policy.

The Commission directed the insurance company to give an amount of Rs. 9,117 to the complainant with 5.5% interest per annum, along with a payment of Rs 10,000 as compensation and Rs 5,000 towards the cost of proceedings.

Counsel for the Complainant: Adv. S. Russel

Counsel for the Opposite Party: Adv. Saji Isaac

Case Title: Sruthy Narayanan Vs. Aditya Birla Health Insurance Company

Case Number: C.C. No.- 230/2020

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