A woman from Zirakpur, Punjab, took her insurance company to the District Consumer Disputes Redressal Commission in Chandigarh after her medical claim was denied. Her perseverance paid off as she was not only granted the full claim but also awarded compensation for mental distress.
Divya Bhola, the policyholder, had purchased a health insurance policy from Religare Health Insurance, which was valid until January 2021. In December 2019, she suffered a severe accident and was rushed to Alchemist Hospital in Panchkula. The accident had left her with multiple fractures on her face, including her nasal bones, necessitating dental treatment.
Religare Health Insurance initially approved a cashless medical reimbursement of ₹44,897, in accordance with the treatment required for her injuries. However, her medical journey did not end there. Dental implantation was recommended as part of her recovery process. Divya Bhola followed her doctor's advice, hoping her insurance would cover these additional expenses.
Divya submitted bills totaling ₹1,23,793, which included charges from the hospital and chemists. Surprisingly, the insurance company only reimbursed ₹8,000, leaving a substantial amount unpaid.
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Religare Health Insurance argued that the hospitalization claim was approved and directly disbursed to the hospital because it was a cashless claim. Subsequently, Divya Bhola filed a post-hospitalization claim for ₹1,18,500, of which only ₹8,000 was approved, specifically for root canal therapy charges. The insurance company contended that the policy's terms and conditions excluded dental charges related to implants. The policy stated that implants and cosmetic surgery were not covered.
However, the District Consumer Disputes Redressal Commission disagreed with the insurance company's interpretation. The court ruled that the exclusion clause did not apply in this case because the dental implantation was necessitated by the accident. It was not a cosmetic procedure. The court also criticized insurance companies for imposing unilateral terms on consumers who pay significant premiums but face difficulties during reimbursement.
The court's judgment was clear: the insurance company had to pay the outstanding claim amount of ₹1,15,793, along with 9% annual interest from the date of the complaint. Additionally, the insurance company was ordered to pay ₹10,000 as compensation for the mental distress and harassment Divya Bhola endured throughout this process. A further ₹5,000 was awarded as the cost of litigation.
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This case serves as a reminder of the importance of understanding the terms and conditions of insurance policies. It also highlights the need for consumers to assert their rights when they believe their claims have been unjustly denied. In this instance, the District Consumer Disputes Redressal Commission's decision brought justice to Divya Bhola, ensuring she received the financial support she was entitled to during her recovery.
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