Insurer rejects heart treatment claim over ‘no original records’, family wins Rs 13.8 lakh

Similarly, for the 2014-15 policy, the commission noted that the coverage was Rs 6.25 lakh and awarded the amount within that limit.

It held that rejecting the claims solely on the ground that original documents were not submitted was improper, particularly when the complainants had provided notarised/certified copies and were willing to produce the originals for verification.

Family seeks insurance claim settlement

The deceased man’s wife and two sons, who are the complainants in the case, approached a private insurance company alleging that it had failed to settle the medical insurance claim arising from the man’s treatment.

The deceased had been covered under the insurer’s family plan continuously from 2010. His coverage for 2014-15 was Rs 6.25 lakh, including a Rs 1.25 lakh bonus, while the 2015-16 policy provided total coverage of Rs 6.50 lakh, including a Rs 1.50 lakh recharge benefit.

In March-April 2015, the deceased underwent treatment at AIIMS Delhi, where he was diagnosed with a serious cardiac condition. The family incurred Rs 4.22 lakh in medical expenses, but the insurer did not pay the claim.

He was then treated at Care Hospital, Hyderabad, where expenses of Rs 6.83 lakh were incurred. He was later admitted to Fortis Hospital, Chennai, where he died on July 29, 2015, following multi-organ failure and RV (heart) dysfunction. His treatment and hospitalisation there cost another Rs 12.04 lakh.

The complainants said the insurer failed to reimburse the eligible expenses under the policies. The insurer had rejected the claim, citing non-submission of original documents, stating that despite reminders, the required documents had not been provided.

The family then filed the consumer complaint in 2016, alleging deficiency in service and unfair trade practice, and seeking reimbursement, compensation, and litigation costs.

Family failed to submit originals: Insurer

The insurance company rejected the claim on the ground that the complainants had failed to submit the original documents required for processing it.

It stated that despite repeated reminders, the required documents were not furnished and, hence, it presumed that the complainants were not interested in pursuing the claims. The claims were consequently repudiated.

‘Claim can’t be rejected without documents’

The commission observed that the complainants had continuously obtained health insurance policies from the insurer since 2010 and had submitted the relevant claim documents.

“The courts, including the national commission and the state commission, have held that it is not proper to dismiss a claim merely due to the absence of documents. Dismissing a claim solely because the original documents were not produced is contrary to law and amounts to deficiency in service and an unfair trade practice,” the order said.

For the 2014-15 policy, the commission noted that the coverage was Rs 6.25 lakh and awarded the amount within that limit, despite the medical expenses being higher. For 2015-16, it similarly restricted the claim to the policy coverage of Rs 6.50 lakh.

Takeaway

The order underscored that insurers cannot reject genuine medical claims solely for non-submission of original documents when certified copies are available and verification remains possible. It also reinforces that compensation must remain within the policy’s insured limits.

Consumers facing similar grievances may contact the consumer helpline in their respective states (Chhattisgarh: 1800-233-3663) or dial the National Consumer Helpline at 1915 for assistance.

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