The District Consumer Disputes Redressal Commission has ordered an insurance company to pay compensation to a policyholder after rejecting his health claim.
The complainant, Mulangadan Mohammed Rafi, a resident of Edavanna, was treated at a private hospital in Manjeri. He later submitted his medical bills to the insurance company. The claim was not accepted. The insurer said that Rafi had not disclosed a previous illness when he took the policy. It also said that all treatment records had not been given.
Rafi filed a complaint before the Consumer Commission. The Commission examined the case. It found that the insurance company had not provided proof to back its statements. No record was produced to show that the complainant had hidden any illness. No material was shown to prove that treatment papers were missing.
What Did The Commission State
The Commission stated that the denial of the claim was without proper reason. It held that the insurer had failed in its service to the customer.
The order directed the company to pay Rs 1,26,269 to Rafi, which was the treatment cost. In addition, the company has been asked to pay Rs 1 lakh as compensation. This brings the total to Rs 2,26,269.
The Commission said that the money should be paid within one month. If the payment is delayed, the amount will carry interest at nine per cent per year until it is cleared.
Consumer forums across the State are receiving many complaints about health insurance. Rejection of claims on grounds of non-disclosure of illness is a common issue. Commissions have repeatedly said that insurers must prove such charges with documents.
In this case, the insurer could not do so. The Commission concluded that the complainant was entitled to the amount. The ruling provides relief to Rafi, who had faced difficulty after his medical expenses were not covered.
The decision also serves as a warning to insurers. The forums will take action if companies deny claims without evidence. Penalties may be imposed along with the original claim amount.
