Not too long ago, the Thane District Shopper Disputes Redressal Fee bench comprising V.C. Premchandani (President) and Poonam V. Maharshi (Member) held Star Well being And Allied Insurance coverage Co. Ltd. liable of deficiency in service for rejecting the insurance coverage declare filed by the complainant for bills he incurred throughout his therapy at Jupiter Lifeline Hospital Ltd. (Thane).
Temporary Details of the Case:
In 2013, Mr. Diliprao D. Mohite (“Complainant”), a resident of Kisan Nagar in Wagle Property, Thane, obtained a medical insurance coverage coverage from Star Well being and Allied Insurance coverage Co. Ltd. (Insurance coverage Firm). This coverage supplied protection for as much as Rs. 5.5 lakh and required an annual premium cost of Rs. 23,976.
Subsequently, the Complainant skilled extreme coronary heart ache, resulting in his admission to Jupiter Lifeline Hospital Ltd. (“Hospital”) in Thane. Whereas within the hospital, he duly knowledgeable the insurance coverage firm about his medical situation and filed a declare for reimbursement of his medical bills. The hospital acquired the preliminary declare quantity. Nevertheless, the complainant realized that the remaining bills incurred throughout his therapy weren’t lined by the insurance coverage coverage. In response, he approached the insurance coverage firm to say the excellent quantity.
The insurance coverage firm contended that their repudiation of the complainant’s was justified, primarily citing the coverage’s exclusion clause which explicitly excluded bills incurred primarily for diagnostic functions, X-ray examinations, or laboratory examinations that weren’t according to or incidental to the analysis and therapy of an ailment. It additional contended that the Complainant’s hospitalization was primarily diagnostic and, due to this fact, the exclusion clause was relevant. On the opposite hand, the hospital disassociated itself from any wrongdoing and emphasised that there was no direct relationship between its facility and the insurance coverage firm.
Observations by the Fee:
The District Fee famous that the complainant’s admission to the hospital was not solely for diagnostic functions however was necessitated by extreme coronary heart ache, which was subsequently recognized as Paroxysmal AF with CVA. The medical information and discharge abstract indicated that the complainant’s hospitalization was certainly for therapy, as supported by the analysis and the next medical selections.
In gentle of this important statement, the District Fee dominated that the exclusion clause, which excluded diagnostic bills unrelated to therapy, didn’t apply to the complainant’s scenario. It was decided that the complainant’s hospitalization was not merely for diagnostic functions, because the insurance coverage firm had asserted, however was medically warranted for the therapy of his coronary heart situation.
Consequently, the District Fee discovered that the insurance coverage firm had dedicated a deficiency in service by erroneously repudiating the complainant’s declare. The District Fee directed the insurance coverage firm to pay the complainant an quantity of Rs. 33,500 at a fee of 8 per cent each year. It was additionally directed to pay the complainant compensation of Rs. 15,000 for the psychological agony endured and Rs. 5,000 in the direction of the prices of the criticism.
Case: Diliprao D Mohite vs. M/s Star Well being and Allied Insurance coverage co Ltd
Case No.: CC/558/2017
Advocate for the complainant: Adv Nanabhau Varkhate & Adv Mahesh Solanke
Advocate for the Respondent: Adv Balaji Umate
Click on Right here To Learn/Obtain Order