Insurer rejects claim citing break in policy renewal, consumer forum says ‘unjustified'
In its order dated July 15, the commission, headed by Praveen Kumar Jain, ruled that the Chennai-headquartered insurer must pay the amount via its Ghaziabad office within 45 days. Failing to do so would attract an interest of 6% per annum until the claim is settled.
The forum also imposed Rs 5,000 as litigation costs and compensation for mental harassment caused to the consumer.
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The case was filed by Rajendra Prasad, a resident of Bulandshahr, who approached the consumer forum in Sept 2021.
Prasad said he purchased a Family Health Optima insurance policy in 2018 that covered him, his wife Sarla Devi, and son Akshay Tomar. The Rs 5.5 lakh family floater policy, purchased from the insurer's Ghaziabad branch, had been renewed each year without fail, he said.
In early 2021, Prasad was admitted to Narendra Mohan Heart Hospital in Ghaziabad with chest pain from Jan 5 to 10, followed by a second hospitalisation at Shankar Lal Hospital from Jan 16 to 21 due to high fever and complications.
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He spent around Rs 1.9 lakh at the first, empanelled hospital and Rs 50,000 at the second.
However, Star Health rejected his claim, citing a "break in policy renewal".
Prasad challenged the insurer's stand, stating that he never allowed the policy to lapse and had renewed it well in time.
When served notice, the company initially failed to respond, prompting the commission to initiate ex-parte proceedings. Later, the insurer argued that the claim was rightly rejected as Prasad renewed the policy when he was already unwell.
After reviewing the case, the commission concluded that this was not a valid reason to deny the claim. "The complainant was admitted on Jan 5, and even if he fell ill on Jan 3—the date of policy renewal—the policy was in force on the date of admission," the commission observed.
Since both hospital stays fell within the policy's validity period, the commission held the insurer responsible for inadequate service and ordered it to settle the full claim.
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