From Financialexpress · FE News Desk · · 1m 30s
Insurer Ordered to Pay Rs 1.98 Lakh for Surgery Rejection
Delhi consumer commission forces insurer to pay Rs 1.98 lakh after rejecting sleep apnoea surgery claim due to 48-month waiting period.
In brief
Delhi consumer commission forces insurer to pay Rs 1.98 lakh after rejecting sleep apnoea surgery claim due to 48-month waiting period. A Delhi consumer commission ordered a private health insurer to pay Rs 1.98 lakh to a policyholder whose sleep apnoea surgery claim was rejected due to a 48-month waiting period for…
Insurer rejects surgery claim
The insurer rejected the policyholder's request for cashless treatment and reimbursement for sleep apnoea surgery after citing a 48-month waiting period for pre-existing conditions.
Policyholder challenges rejection
The policyholder argued the rejection was unjustified and approached the Delhi consumer commission on August 14, 2024, seeking reimbursement and compensation.
Commission finds no medical proof
The commission found the insurer failed to produce medical evidence showing the policyholder had sleep apnoea before purchasing the policy, which began on June 4, 2021.
Awarded Rs 1.98 lakh
The commission ordered the insurer to pay Rs 1,73,010 for medical expenses, 7% interest, Rs 20,000 for mental agony, and Rs 5,000 for litigation costs, totaling Rs 1,98,010.
Insurer's justification
The insurer claimed the policyholder had been using CPAP therapy since 2021 and had depression, but failed to provide medical records by April 15, 2024.
Commission's ruling
The commission held the insurer guilty of deficiency in service and unfair trade practice, directing payment with interest and additional compensation.
Key takeaway
Policyholders should retain medical records and claim-rejection letters to challenge insurers when waiting periods are applied without adequate evidence.
The short version
A Delhi consumer commission ordered a private health insurer to pay Rs 1.98 lakh to a policyholder whose sleep apnoea surgery claim was rejected due to a 48-month waiting period for pre-existing conditions.
