Religare Health Insurance Ordered To Pay ₹8.56 Lakh For Denied Chemotherapy Bills By Consumer Commission

Insurance Commission Orders Religare to Pay Rs 8.56 Lakh for Chemotherapy.

Expert Analysis:

• Commission Reprimands Religare for Chemotherapy Denia: The Suburban Mumbai Additional District Consumer Dispute Redressal Commission (DCDRC) has reprimanded Religare Health Care Insurance for refusing to cover chemotherapy expenses, citing the consumer's failure to disclose her medical conditions of hyper-lipidemia and allergic asthma.

• Commission's Financial Orders Against Insurance Firm: The commission has ordered the insurance firm to pay Rs 8,56,592 for the complainant’s medical bills, along with 9% interest from November 2014. Additionally, they must refund the policy amount of Rs 24,875, accompanied by additional amounts of Rs 25,000 and Rs 15,000 towards the complainant’s mental agony and litigation charges, accordingly.

• Medical Treatment and Insurance Claim Submission: Hitesh Sheth from Ghatkopar bought a Rs 24,875 mediclaim policy with Religare Health Care starting November 30, 2013. In April 2014, his wife Anjana underwent surgery and chemotherapy at Somaiya Ayurvihar Asian Institute of Oncology for breast conditions. They submitted the medical bills to the insurer for reimbursement.

• Claim Rejection: The insurance firm cited undisclosed hyper-lipidemia and allergic asthma as grounds to reject Anjana's claim for chemotherapy expenses.

• Firm's Response on Medical History: The forum, upon reviewing the evidence, requested the insurance firm to respond. The company stated, "Medical documents show that the complainant's wife had known hyper-lipidemia and allergic asthma since 2005, which were not disclosed in the policy proposal. Therefore, the claim was rejected based on policy terms."

• Commission Rejects Company's Defense: The commission, however, rejected the company’s say and asked them to pay for the complainant’s medical expenses.