Rashmi Gupta, a Dasna resident in Ghaziabad district, approached the Ghaziabad District Consumer Disputes Redressal Commission on Nov 30, 2022, seeking direction for the insurance company to settle her claim of Rs 1.68 lakh, which she paid to a ‘ClearMedi Healthcare and Cancer Hospital‘ after being admitted and treated there for Covid.
Gupta told the commission that her husband, Rahul Gupta, took the Family Health Optima Insurance Plan from Star Health Insurance on Jan 25, 2021, after paying a premium of Rs 11,198. The policy, with a sum insured value of Rs 5 lakh, covered Rahul Gupta himself, his wife i.e. claimant Rashmi Gupta, and their three children.
Rashmi tested positive for the Sars Cov2 virus, and was hospitalized on April 22, 2021. In the absence of vacant beds in the hospital she was taken to emergency and critical care room of ClearMedi Healthcare and Cancer Hospital. She was discharged five days later on April 27 and the family paid Rs 1,68,998 to the hospital. When Rashmi claimed for reimbursement, it was rejected on the grounds that the policyholder could have been treated in home isolation.
Filing a counter-argument, the Star Health Insurance company said that as per the hospital records, the patient’s SPO2 level was normal. Other parameters were normal, and all the test reports were within normal limits. Saying further, the findings confirm that the insured, a Covid patient, did not require hospitalisation. According to Star Health Insurance, the maximum liability in respect of policy is not more than Rs 97,695.
Having heard both parties, The Ghaziabad District Consumer Disputes Redressal Commission agreed that the policy issued by the insurance company is subject to the guidelines and exclusions. But the commission stated that the insurance company can deduct the room rental as per regulations but has to settle the claim and directed Star Health and Allied Insurance Company to pay Rs 1.1 lakh (after deductions and exclusions) towards hospitalisation expenses to the policyholder i.e. Rahul Gupta within 45 days. The company was also fined Rs 5,000 for litigation costs and mental agony, with the commission ruling that whether a patient needs hospitalisation or not is decided by a doctor and not the insurance company.