Case Title: Himanshu Yadav vs Manasavi Hospital & Trauma Centre and Anr.
Summary
The District Consumer Disputes Redressal Commission in Rewari, Haryana, has found TATA AIG General Insurance Company liable for the wrongfully rejected medical claim based on fictitious and ambiguous grounds. The insurance company claimed the insured had committed fraud but neglected to verify the authenticity of his medical records. The complainant lodged a consumer complaint against the insurance company with the District Commission, arguing that the claim was legitimately repudiated due to the complainant’s failure to submit necessary documentation. The District Commission determined that the insurance company erroneously and unlawfully rejected the claim, resulting in unjust treatment. The Commission emphasized the insurer’s responsibility to settle claims within 30 days of obtaining all necessary documents, and held the insurance company accountable for the discriminatory denial of reimbursement for medical expenses.
About the case
Shri Sanjay Kumar Khanduja (President) and Shri Rajender Parshad (Member) of the District Consumer Disputes Redressal Commission, Rewari (Haryana), have found TATA AIG General Insurance Company to be liable for the wrongfully rejection of a medical claim on the basis of fictitious and ambiguous grounds. The Insurance Company claimed that the insured had committed fraud; however, it neglected to verify the authenticity of his medical records prior to rendering a determination.
The complainant acquired a health insurance policy from TATA AIG General Insurance Company Ltd (“Insurance Company”). The Complainant experienced symptoms such as fever, body aches, and agony during the policy period. The Complainant sought medical assistance and was admitted to Manasavi Hospital & Trauma Centre on 14.05.2022. She remained there until 18.05.2022. The insurance company rejected the claim in a letter, alleging that the Complainant had been dishonest in pursuing the claim, despite the fact that all necessary documents had been submitted. However, the Complainant did not receive a satisfactory response from the insurance company, despite the fact that they made numerous communications. The Complainant lodged a consumer complaint against the insurance company with the District Consumer Disputes Redressal Commission, Rewari, Haryana (“District Commission”), as a result of feeling aggrieved.
The insurance company argued that the claim was legitimately repudiated as a result of the Complainant’s failure to submit the necessary documentation. Furthermore, it contended that the hospital, which was owned by Navneet Kumar and had a separate policy with the insurance company, was denied his claim due to deceit. It contended that the repudiation was justifiable and encouraged the District Commission to disregard the complaint.
The District Commission determined that the insurance company erroneously and unlawfully rejected the Complainant’s legitimate medical reimbursement claim, resulting in unjust treatment. The letter’s rejection remarks were lacking in specificity and clarity with respect to the purported dishonesty that occurred during the claim submission process.
It was determined that the insurance company’s failure to specify the nature of the purported fraud or dishonesty committed by the Complainant, in conjunction with the absence of any indication that the hospitalization was fictitious. It eroded the credibility of the claim’s rejection. The insurance company was deemed to have neglected to pursue this course of action, despite the opportunity to appoint an investigator to verify the authenticity of the medical documents.
The District Commission emphasized the insurer’s responsibility to promptly settle claims within 30 days of obtaining all necessary documents, citing the guidelines issued by the Insurance Regulatory and Development Authority of India (IRDAI). Consequently, the District Commission held the insurance company accountable for the deficiency in services that resulted from the discriminatory denial of reimbursement for medical expenses.
As a result, the District Commission instructed the insurance company to promptly reimburse the Complainant for Rs.74,843/- and to provide Rs. 20,000/- in compensation for the distress it has caused.
