Mohali: Insurer to cough up ₹2 lakh for denying mediclaim
The District Consumer Disputes Redressal Commission, Mohali, has directed HDFC ERGO Health Insurance Limited (formerly Apollo Munich Health Insurance) to reimburse ₹2 lakh to a policyholder for wrongly denying a mediclaim.
The commission also awarded ₹30,000 as compensation for mental harassment and litigation costs.
The complainant, Kuldeep Singh Sandhu, a resident of TDI City, Sector 117, Kharar, informed the commission that he had bought a group mediclaim policy from Apollo Munich through Canara Bank's Phase 10 branch.
The policy, issued in the name of his wife, Jaspal Kaur, provided both of them a ₹5-lakh cover and was valid from November 30, 2019, to November 29, 2020.
On March 6, 2020, he was admitted to Sri Guru Harkrishan Sahib Eye Hospital, Sohana, after vomiting, gait ataxia, vertigo, slurred speech and numbness in the face.
The hospital sent a request to HDFC ERGO for cashless treatment, but the insurer denied it on March 9, citing pre-existing Coronary Artery Disease (CAD) as the reason. The policy was subsequently terminated on March 10.
The complainant contested the CAD claim, submitting medical evidence from a cardiologist, who certified on March 11, 2020, that Sandhu had no cardiac symptoms or history of CAD.
Another certificate from another doctor clarified that a blood thinner prescribed to Sandhu since 2008 was being used purely as a preventive measure.
Despite this, the insurer did not approve the claim or reimburse the hospital expenses, forcing the complainant to pay ₹1,01,953 for the March 6 hospitalisation and ₹99,053 for a second admission on March 18 for similar symptoms. The total out-of-pocket expense amounted to over ₹2 lakh.
The commission noted that the insurer did not produce any credible evidence proving Sandhu had CAD prior to the policy's inception.
Holding HDFC ERGO guilty of deficiency in service and unfair trade practices, the commission remarked that insurance companies often enticed customers at the time of policy sale but shirked responsibility when it came to settling genuine claims.
The insurer was, thus, directed to reimburse the full hospital bill with 6% annual interest from the date of discharge (March 23, 2020) within 30 days, failing which the interest rate will increase to 9% per annum.
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Mohali: Insurer to cough up ₹2 lakh for denying mediclaim
The District Consumer Disputes Redressal Commission, Mohali, has directed HDFC ERGO Health Insurance Limited (formerly Apollo Munich Health Insurance) to reimburse ₹2 lakh to a policyholder for wrongly denying a mediclaim. The commission also awarded ₹30,000 as compensation for mental harassment and litigation costs. The complainant, Kuldeep Singh Sandhu, a resident of TDI City, Sector 117, Kharar, informed the commission that he had bought a group mediclaim policy from Apollo Munich through Canara Bank's Phase 10 branch. The policy, issued in the name of his wife, Jaspal Kaur, provided both of them a ₹5-lakh cover and was valid from November 30, 2019, to November 29, 2020. On March 6, 2020, he was admitted to Sri Guru Harkrishan Sahib Eye Hospital, Sohana, after vomiting, gait ataxia, vertigo, slurred speech and numbness in the face. The hospital sent a request to HDFC ERGO for cashless treatment, but the insurer denied it on March 9, citing pre-existing Coronary Artery Disease (CAD) as the reason. The policy was subsequently terminated on March 10. The complainant contested the CAD claim, submitting medical evidence from a cardiologist, who certified on March 11, 2020, that Sandhu had no cardiac symptoms or history of CAD. Another certificate from another doctor clarified that a blood thinner prescribed to Sandhu since 2008 was being used purely as a preventive measure. Despite this, the insurer did not approve the claim or reimburse the hospital expenses, forcing the complainant to pay ₹1,01,953 for the March 6 hospitalisation and ₹99,053 for a second admission on March 18 for similar symptoms. The total out-of-pocket expense amounted to over ₹2 lakh. The commission noted that the insurer did not produce any credible evidence proving Sandhu had CAD prior to the policy's inception. Holding HDFC ERGO guilty of deficiency in service and unfair trade practices, the commission remarked that insurance companies often enticed customers at the time of policy sale but shirked responsibility when it came to settling genuine claims. The insurer was, thus, directed to reimburse the full hospital bill with 6% annual interest from the date of discharge (March 23, 2020) within 30 days, failing which the interest rate will increase to 9% per annum.
