The District Consumer Disputes Redressal Forum (I) has directed Star Health and Allied Insurance Company Limited to pay around Rs 2 lakh to an elderly patient, whose medical expenses were not reimbursed despite the fact that he had a health insurance policy of the company.
In his complaint, Naresh Kumar Juneja, a resident of Sector 9, stated that he had taken a medi-claim insurance policy of the company in 2012 with an insured sum of Rs 5,00,000. He got it renewed next year and in 2014.
On January 31 last year, the complainant was hospitalised and diagnosed with acute promyelocytic leukaemia-M2. The policy was in existence then.
He incurred Rs 6,37,514 on treatment of the disease. Juneja requested the company for the cashless facility, which was rejected.
Thereafter, he again fell ill and was diagnosed to be suffering from phemonia. The complainant took the treatment from Fortis Hospital, Mohali, and was discharged in March last year.
Juneja spent Rs 4,68,085 on treatment. It is observed that the complainant received a letter during his admission in the hospital stating that his claim was repudiated on account of non-disclosure of material fact i.e. about the existence of pre-existing disease and they further cancelled the policy on a pro-rata basis and refunded the premium for the remaining period.
The court ordered the insurance company to pay 1,80,000 as per Clause-G of the terms and conditions of the policy to the complainant.
It also directed the company to pay Rs 20,225, the premium amount for the remaining period of the policy cancelled on a pro-rata basis.
Besides, it further ordered the insurance firm to pay Rs 15,000 to the complainant as compensation on account of deficiency in service, unfair trade practice and causing mental agony and harassment as well as litigation expenses.