In a significant ruling reinforcing policyholder rights, the District Consumer Disputes Redressal Commission (DCDRC) in Noida has directed Reliance General Insurance Company Limited (RGICL) to settle a long-pending mediclaim exceeding Rs 51,000. The commission emphatically stated that an insurance company cannot reject a valid claim based solely on grounds of suspicion.
The Three-Year Ordeal of a Policyholder
The case involved Anil Kumar, a resident of Bambawar, who held a family health policy worth Rs 6 lakh with Reliance General Insurance, purchased after paying a premium of Rs 12,584. The policy was valid from February 16, 2022, for one year. Within this period, Kumar fell ill and was admitted to Sanjeevni Hospital in Greater Noida on March 16, 2022.
He was discharged on March 19. However, complications arose the same evening, forcing his immediate readmission, this time at Tirupati Hospital in Ghaziabad. While the insurer settled the claim of Rs 45,478 for the first hospitalization, it refused to pay the Rs 51,462 bill for the treatment at Tirupati Hospital. The company rejected the claim on April 23, 2022, alleging the submitted documents were "ingenuine and fabricated."
Consumer Commission's Firm Stand and Order
Frustrated by the denial, Anil Kumar approached the DCDRC on October 21, 2022, seeking payment of his claim and Rs 20,000 as compensation for deficiency in service. After examining the evidence, the commission, comprising President Anil Kumar Pundir and Member Anju Sharma, delivered its order on November 26.
The panel dismissed the insurer's argument that the second admission was "on paper" and that no payment was made. "We can see receipts of payments made against pathological investigation, admission, and treatment in the hospital along with the invoice of medicines," the commission noted. It also logically observed that "after being discharged from one hospital, any person can fall ill again, requiring treatment in hospital after admission."
Key Directives of the DCDRC
The commission issued clear directives to Reliance General Insurance:
- Settle the outstanding claim amount of Rs 51,462.
- Pay interest on this amount at the rate of 6% per annum from the date of filing the complaint until final payment.
- Pay Rs 2,000 to the complainant as litigation costs.
- Complete the entire settlement within 30 days of the order.
A Precedent Against Arbitrary Claim Rejections
This ruling sets a crucial precedent for insurance consumers across India. By clarifying that suspicion alone is not a valid ground for claim rejection, the DCDRC has strengthened the legal shield for policyholders. The decision underscores the duty of insurance companies to conduct thorough, good-faith investigations before denying a claim, especially when valid documentation is provided.
For Anil Kumar, the order brings an end to a three-year wait for rightful compensation. For the broader public, it serves as a powerful reminder of the recourse available through consumer forums when faced with unfair insurance practices.
