Health insurer fined Rs 30,000 for denying medical claim, directed to pay Rs 2 lakh with interest
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Mohali: The District Consumer Disputes Redressal Commission, Mohali, has directed HDFC ERGO Health Insurance Ltd (formerly Apollo Munich Health Insurance) to pay Rs 2.01 lakh along with interest and Rs 30,000 as compensation to a policyholder for wrongfully denying a mediclaim.
The commission, presided over by S K Aggarwal and member Paramjeet Kaur, held the insurer guilty of negligence and deficiency in service for rejecting the genuine claim of complainant Kuldeep Singh Sandhu, a resident of TDI City, Sector 117, Kharar.
Sandhu had purchased a group mediclaim policy through Canara Bank's Phase 10, Mohali branch. The policy, valid from Nov 30, 2019, to Nov 29, 2020, was in the name of his wife Jaspal Kaur and covered both spouses for a sum insured of Rs 5 lakh.
On March 6, 2020, Sandhu was admitted to Sri Guru Harkrishan Sahib (C) Eye Hospital, Sohana, with symptoms such as vomiting, vertigo, slurred speech, and facial numbness. However, his request for cashless treatment was denied by HDFC ERGO on March 9, citing pre-existing coronary artery disease (CAD). The policy was subsequently terminated on March 10.
The complainant contested the insurer's stand, providing medical certificates from Dr Mohit Walia, a cardiologist, and Dr RS Paik, who confirmed there was no history of CAD.
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Despite this, the insurance company refused to reimburse the hospital expenses.
Sandhu had to pay Rs 1,01,953 for his first admission and Rs 99,053 for a second hospitalisation on March 18 for similar symptoms — totalling Rs 2,01,006 out of pocket.
The commission noted the insurer failed to provide credible proof of any pre-existing illness and accused it of adopting unfair trade practices. "Insurance companies entice customers at the time of policy sale but try to escape responsibility when it comes to settling genuine claims," observed the commission.
The company has been directed to pay the full amount with 6% annual interest from the date of discharge (March 23, 2020), failing which the interest will rise to 9%. The insurer has also been permitted to seek any pending documentation from the complainant within 30 days.
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