Class 10 Student Vs Insurer: Consumer Court Slams Company

A consumer court in Gujarat has criticised an insurance company for denying the mediclaim of a Class 10 student who appeared for his board examinations while recovering from surgery. The forum observed that the boy’s determination to sit for the exams despite a serious medical condition should have been appreciated rather than used as a ground to deny his claim.

The order came from the consumer disputes redressal commission in Surat after the student’s family challenged the insurer’s decision to reject the reimbursement request for hospital expenses. The commission held that the reasoning adopted by the insurer did not stand up to scrutiny, according to a recent report by “The Times of India.”

Medical Emergency During Board Exams

The dispute began after the father of the student, a trader from Surat, purchased a health insurance policy with a sum insured of Rs 5 lakh starting January 24, 2020.

During the policy period, the boy complained of intense abdominal pain on March 11 and was rushed to the hospital. Doctors later diagnosed him with perforated appendicitis and operated on him the same day.

The timing of the illness created an additional challenge. The incident came while he was writing his Class 10 board exams. Missing the papers could have meant losing a full academic year.

According to records presented before the commission, the student sought permission from his doctors to appear for the exams. The treating doctor eventually permitted him to sit for the exams, subject to medical precautions.

Even after the surgery, the student appeared for his examination papers while still recovering. He was discharged from the hospital on March 19. The family later filed a claim of Rs 2.02 lakh with the insurer for the treatment expenses.

Insurer’s Rejection Challenged

The insurer turned down the claim on May 22. It argued that since the student had appeared for the examinations, hospitalisation may not have been necessary. Challenging the rejection, the family approached the Surat Consumer Disputes Redressal Commission in January 2021 seeking reimbursement and compensation.

During the hearing, the complainant’s counsel argued that the decision to allow the student to write his examinations had been made by the treating doctor. It was done purely to ensure that the student’s academic year was not wasted.

The lawyer maintained that appearing for the exams did not change the fact that the boy had undergone surgery for a serious medical condition and had remained hospitalised for treatment.

After examining the documents and submissions from both sides, the consumer commission found fault with the insurer’s reasoning.

The forum observed that when a student who has undergone surgery still makes the effort to sit for board examinations, such determination deserves appreciation. Using that effort as the basis for denying a legitimate medical claim, the commission said, was unjustified.

The court ruled in favour of the complainants and directed the insurance company to pay Rs 2.02 lakh towards the medical claim.

In addition, the commission ordered the insurer to pay interest at 8 per cent on the amount from the date the claim was filed. The commission also asked the insurer to pay Rs 12,000 as compensation to the family and Rs 8,000 towards legal costs.

The order makes it clear that insurers cannot deny claims on assumptions when medical records support the treatment. It also shows that policyholders can seek relief through consumer forums when they believe a claim has been wrongly rejected.