In a decisive ruling on Monday, the District Consumer Disputes Redressal Commission-2, Chandigarh, chastised Aditya Birla Health Insurance for unfairly denying a medical claim, resulting in an order to pay ₹69,228 in total, which includes reimbursement for medical expenses, along with compensation for mental harassment and litigation costs.
Sanjeev Rana, a resident of Sector 38 West, Dadumajra, had filed a complaint after his health insurance claim was rejected by the insurance company. Rana, who holds an Active Assure Diamond policy with a coverage of ₹5 lakh, was admitted to Max Super Specialty Hospital in Mohali in April 2024 due to severe dehydration and elevated creatinine levels. Despite the hospital submitting the necessary claim documentation, Aditya Birla Health Insurance declined the claim, arguing that Rana’s hospitalization was unnecessary and his condition could have been managed in an outpatient setting.
The consumer court, led by Commission Chairman Amarinder Singh Sidhu and member Brij Mohan Sharma, ruled against the insurance company, highlighting that it is the treating physician who is best qualified to determine the necessity of hospital admission. The court’s investigation found the insurance provider’s decision to deny the claim to be arbitrary and without merit.
The court ordered Aditya Birla Health Insurance to reimburse Rana ₹54,228 for his medical expenses and pay an additional ₹15,000 for causing mental distress and covering legal expenses. The ruling emphasized the arbitrary nature of the denial, noting the insurer’s promptness in collecting premiums compared to their reluctance in settling claims.
“This judgment underscores the responsibilities that insurers have towards their policyholders and the consequences of disregarding them,” remarked Chairman Sidhu during the delivery of the judgment.
