Insurance co told to pay hosp expenses over service fault

Panaji: The North Goa District Consumer Dispute Redressal Commission ordered ICICI Lombard to pay a Porvorim resident for the hospital expenses on two visits - Rs 13,657 on Jan 20, 2025, and Rs 13,209 for another visit on Feb 8, 2025, along with a compensation of Rs 25,000 with an interest rate of 5% over deficiency of service.

According to the complaint, Ayesha Nasim, a Porvorim resident, fell sick with stomach pain, vomiting and diarrhoea on Jan 20, which lasted for a week. Nasim experienced complete dehydration and weakness and showed no signs of improvement. Nasim was taken to RG Stone hospital for treatment and administered antibiotics and saline.

After getting discharged, she approached ICICI Lombard, where she took her health policy in 2008, and informed the officer about her hospitalisation.

A month later, she fell sick again and was treated with the same medication. She approached the insurance company to claim the health insurance, and accepted the claim. At the time of her discharge, the hospital staff informed her that the insurance company didn’t accept her claim, because of which she had to pay the entire amount to the hospital.

Nasim contacted the firm to enquire why her claim was rejected, and was informed by that it was because she was required to co-pay. She tried explaining that she had been associated with the firm for 11 years and never had to co-pay. Nasim emailed the firm and contacted the officer repeatedly about the issue, but the insurance amount wasn’t paid to her.

She sent a legal notice to the company. The firm argued that as per the policy, any discrepancies or variations must be brought to the company’s attention, and Nasim didn’t submit any request or enquiry. It also argued that the recent hospitalisation didn’t meet the criteria of ‘medically necessary treatment’ according to the policy’s rules , and hence rejected the cashless claim.

The commission observed that looking at the age under which Nasim had to request her insurance claim, the company provided a vague defence on rejecting Nasim’s claim. It also observed that the firm failed to prove that Nasim had to co-pay, and found it liable under deficiency of service.
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