Hospital delay no excuse: Bengaluru consumer panel orders insurer to pay Rs 2.6 lakh | Bengaluru News
Bengaluru: A delay in hospital paperwork earned an insurer a rebuke from the consumer commission, which said the company used the lapse as a flimsy excuse to deny a genuine claim. Bangalore Urban II additional district consumer disputes redressal commission directed Aditya Birla Health Insurance to pay the Rs 2.6-lakh claim.On July 4, 2023, Pavan, 28, a resident of Judicial Layout, north Bengaluru, was admitted to KK Hospital, Yelahanka, after a road accident and treated for a fracture of the face. His mother, Latha K, 51, the primary insured under the firm’s ‘Group Activ Health’ policy, claimed the hospital’s delay in informing the insurer led to the denial of their cashless claim.Forced to pay over Rs 2.6 lakh despite having a Rs 5-lakh cover, Latha filed a reimbursement claim on July 17. The insurer raised tariff-related queries and rejected the claim on Sept 14, citing “bill pendency.” KK Hospital later admitted its delay in notifying the insurance company. Despite visits, calls, emails, and fresh documents — a hospital letter confirming full payment — no reimbursement was issued by the insurance firm.A widow with two children, Latha said she had to borrow money to clear the hospital bill and was facing mental agony and trauma due to repeated rejections. She filed a consumer complaint in March 2024, alleging a deficiency in service and unfair trade practices.In their defence, the insurance firm and KK Hospital told the commission that they followed procedure after the complaint was filed and notices were issued. The insurer said the policy benefits were strictly governed by terms and declarations made at the time of purchase, and the cashless request was denied only because Pavan’s admission at KK Hospital was not reported in time. It said the later reimbursement claim was rejected after a mismatch was found in the hospital tariff, and insisted that the cashless denial was not a final refusal.KK Hospital argued that it was not a necessary party, as the insurance contract existed solely between the complainants and Aditya Birla Health Insurance. It said its role was limited to treating Pavan — who was admitted on July 4, 2023, after a road accident, underwent surgery on July 7, and was discharged the next day — and that any liability lay entirely with the insurer, not the hospital.After reviewing all the documents and hearing both sides, the commission noted that the insurance firm unjustly delayed the settlement of a genuine medical reimbursement claim. The commission observed that there was no dispute over the issuance of the ‘Group Activ Health’ policy covering Pavan with a sum insured of Rs 5 lakh. Documents produced showed that the family spent over Rs 2.6 lakh for the treatment, yet the insurer repeatedly denied the claim, citing late intimation by the hospital. “There is a deficiency in service as OPs (opposite parties) have not settled the genuine claim without valid reasons,” said the commission.The commission bench, comprising president Vijaykumar M Pawale and member Anuradha V, in Nov ordered Aditya Birla Health Insurance to pay Rs 2.6 lakh along with 6% interest from Sept 19, 2023, and Rs 20,000 for mental agony. The complaint against the hospital was dismissed.
