Insurance company directed to settle claim of pregnant woman
The commission directed the company to pay the woman ₹45,704, with 6% interest from the date of repudiation of the claim, October 11, 2023, until the date of realisation. It also directed the firm to pay her ₹10,000 as compensation for the deficiency of service and mental agony. Furthermore, ₹5,000 should be paid to her as the cost of litigation, it stated.
In the judgement on July 18, the commission said that the New Delhi-based Care Health Insurance Limited has not produced any documentary evidence to support its contention that fever, bodyache and throat pain in the claimant, for which she was hospitalised, was on account of pregnancy, and that hospitalisation was not required for these complaints. The company has clearly violated the terms of the health insurance policy by rejecting the claim without any valid grounds, the commission noted.
Ruvin Shain D'Souza, a resident of an apartment in Chilimbi, was offered a Care Health Insurance policy by virtue of being a holder of a savings bank account with the Union Bank of India. Since May 2021, she has paid the premium regularly to renew the policy every year. She paid a premium of ₹10,107 for the policy valid between May 24, 2023 and May 23, 2024.
She was pregnant and had fever, body pain and throatache. On the advice of her doctor, Ms. D'Souza was admitted to Father Muller Hospital on October 9, 2023. She was discharged on October 14, 2023. The hospitalisation and medical expenses charges totalled ₹45,704.
The company rejected her request for a cashless treatment facility, as indicated in letters dated October 11, 2023, and October 13, 2023. The company gave reasons for rejection as 'admission not justified' and 'permanent exclusion admission primarily for investigation and evaluation'.
Terming rejection as a deficiency in service, Ms. D'Souza filed a complaint demanding the settlement of the claim and necessary compensation.
In the judgment, the commission, comprising president Somashekarappa Handigol and member H.G. Sharadamma, observed that the contention of the company was neither supported by medical records pertaining to the claimant nor had it examined the treating doctor to prove its contention.
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