Insurance firm told to pay Rs 3L to woman for denying claim

Excluding C-sections from claims malpractice: Commission

The Punjab State Consumer Disputes Redressal Commission has ordered Star Health and Allied Insurance Company to wage Rs 3 lakh on with costs to Neelam Saini, a nonmigratory of Pakho Chak colony successful Gurdaspur territory for denying her a wellness claim, saying that the institution was not liable to marque immoderate outgo for pregnancy-related cases. The bid reads that “as of contiguous astir deliveries are taking spot done caesarean sections, truthful excluding deliveries and caesarean sections (from the security claims) amounts to a concern malpractice”.

Neelam delivered twins successful Dr Rama Sofat Hospital, Ludhiana, connected June 11, 2022. Following complications successful the caesarean procedure, she was referred to Dayanand Medical College and Hospital successful the city. She remained successful the infirmary till July 17 and incurred an expenditure Rs 4.8 lakh. A assertion of Rs 3 lakh was made arsenic per the security terms, which was rejected by the institution connected ‘vague grounds’.

State committee president Justice Daya Chaudhary and members Simarjot Kaur and Vishav Kant Garg upheld the earlier bid of the District Consumer Disputes Redressal Commission (Gurdaspur), which besides underlined the information that the magnitude was payable with 18 per cent involvement from the day of the ailment till the day of existent payment. The institution had been asked to wage Rs 50,000 arsenic compensation for intelligence harassment and Rs 20,000 much arsenic litigation charges.

The institution argued that, “Exclusion clause (number 18) of the security specifically states that the institution shall not beryllium liable to marque immoderate outgo successful respect of aesculapian expenses incurred, traceable to childbirth (including analyzable deliveries and caesarean sections incurred during hospitalisation) but ectopic pregnancy.”

The committee bid said the argumentation papers fixed to the user did not notation the grounds for exclusion of the claim. ‘We person gone done the argumentation document, which shows that lone argumentation papers comprising 2 pages had been supplied to the complainant and the presumption and conditions and exclusion clause was a abstracted document. It has obscurity been proved connected grounds that the said argumentation papers and conditions and exclusion clause was a portion of the policy. It has besides not been proved that presumption and conditions and exclusion clause No. 18 had been explained to the complainant.”

The committee said that successful lack of grounds regarding presumption and conditions being portion of the argumentation papers and the complainant having been explained astir the same, rejection of the assertion by the other parties was wholly unjustified.

“Moreover, arsenic of contiguous astir of deliveries are taking spot done caesarean sections” truthful “excluding deliveries and caesarean sections (from the security claims) amounts to concern malpractice,” the bid read.