Order Date: 13th May 2024
Order Name: S. Sridevi and Anr. vs The Manager, Star Health and Allied Insurance Co. Ltd. and Anr.
Case No.: Consumer Complaint No. 35/2023
The District Consumer Disputes Redressal Commission in Karur, Tamil Nadu, consisting of N. Pari (President) and A.S. Rathinasamy (Member), ruled in favor of a policyholder against Star Health and Allied Insurance Company. The Insurance firm was found accountable for failing to fulfill a valid health insurance claim, incorrectly attributing it to a pre-existing condition. The panel noted that the medical treatment under the claim didn’t relate to the pre-existing ailment and was not excluded from the insurance policy.
The case involved Ms. S. Sridevi and Mr. B. Siddheswaran, who jointly held a Family Health Optima Insurance Plan with Star Health and Allied Insurance Co. Ltd. This policy had a cover of Rs. 10,00,000/-, with an additional recharge benefit of Rs. 5,00,000/-. The duo maintained that they had regularly renewed their policy until 2022, which was set to expire on 9th September 2023.
During the active policy period, one of them sought medical treatment at G. Kuppusamy Naidu Memorial Hospital in Coimbatore. They filed a claim for cashless treatment on 24th September 2022. However, the Insurance Company demanded certain documents before approving the claim. They later rejected the claim due to non-submission of the requested documents, suggesting reimbursement as an alternative.
Even after submitting the necessary paperwork, the Insurance Company denied the claim on 11th November 2022. They alleged that the claimants had misrepresented facts about their prior medical history of Psoriasis. Despite several attempts to resolve the issue, the matter remained unsettled, leading the policyholders to file a complaint with the District Consumer Disputes Redressal Commission in Karur, Tamil Nadu.
The Commission observed that while the claimant did have a history of Psoriasis, the treatment sought was for a condition called Basilar Dissection, not related to Psoriasis. The Commission stated that disclosing pre-existing conditions in insurance is to avoid fraudulent claims and found no relation between the claimed treatment and the pre-existing condition. The Commission also emphasized that insurance companies are obliged to honor claims for sudden illnesses not explicitly excluded in the policy.
In the final ruling, the District Commission instructed the Insurance Company to pay the medical expenses amounting to Rs. 6,93,642/-, Rs. 2,00,000/- for compensation, and Rs. 10,000/- for litigation costs to the Complainants.
In conclusion, it’s essential to understand that insurance companies have a duty to honor claims that don’t fall under the policy’s exclusion list, even if the policyholder has a pre-existing condition, as long as the claim is unrelated to that condition. This case serves as a reminder to all policyholders to be aware of their rights and the obligations of their insurance providers.
