Gujarat: Insurance firm to pay anaemic man’s hospital bill

VADODARA: Weakness and body ache due to anaemia cannot be seen as a rundown condition or cause of nutritional deficiency, ruled a consumer court here.
The court recently ordered National Insurance Company Ltd to pay the treatment expenses amounting to Rs 33,820 to the complainant Ashish Bhatt along with 9% interest and a compensation of Rs 10,000, as the insurance company could not substantiate its claim that Bhatt’s condition was due to nutritional deficiency.Bhatt had approached consumer court in August 2015 as the third-party administrator on behalf of the insurance company had rejected his claim stating that treatment related to nutritional deficiency is not payable as per the terms and conditions of the health insurance policy.
The insurance firm had also stated that anaemia is a nutritional deficiency in the claim rejection letter. Bhatt was admitted to a private hospital in Nizampura for five days in May 2015 for problems related to his condition. Bhatt, in his complaint, had told the court that the insurance company never gave him a copy of the policy’s terms and conditions.
The court upheld the argument that the copy of terms and conditions was never given to Bhatt, but also drew attention that it cannot be assumed that anaemic condition was due to nutritional deficiency or by not having proper food. “The insurance company should have proven its stand on nutritional deficiency by providing a doctor’s opinion and nutritional deficiency cannot be the only reason for anaemia. So, the insurance company has taken the decision of rejecting the claim by going beyond its power and the TPA on behalf of the insurance company too has decided things based on assumption,” the court noted.