Representative image for health insurance.
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A consumer court in the city recently ruled that alcohol consumption cannot be used as a ground to deny a reimbursement claim under a legitimate health insurance policy.
The ruling stems from a case involving an insurance company’s refusal to reimburse a policyholder under a valid health insurance scheme.
BS Jaisimha, a resident of Nagavara Palya, filed a complaint with the Bengaluru Urban 4th Additional District Consumer Disputes Redressal Commission on December 3, 2021, alleging that Reliance General Insurance Company had provided deficient service by rejecting his claim for reimbursement amounting to Rs 2,55,876 for his hospital expenses.
Jaisimha had paid an annual premium of Rs 26,091 in 2020 for a health insurance policy that remained valid till May 16, 2021. This policy, with a coverage of Rs 3,00,000, provided medical emergency coverage for both him and his wife.
On April 23, 2021, Jaisimha was admitted to a private hospital in the city due to five episodes of hematemesis (vomiting blood). After three days of hospitalisation, he was billed Rs 2,55,876. However, his insurance claim was rejected by the company, forcing him to cover the entire expense.
During the court proceedings, the company’s advocate attributed Jaisimha’s condition to his history of alcohol consumption, citing it as a basis for claim rejection, according to the company’s terms of exclusion.
However, the court ruled that alcohol consumption is a common lifestyle choice and does not automatically render people ineligible for health
insurance.
In this case, no concrete evidence has been provided to substantiate that Jaisimha was an alcoholic.
The court concluded that the company had rejected the complainant’s claim on weak grounds, constituting a deficiency of service.
Final figures
It ordered the company refund the claim amount of Rs 2,55,876 with an 8% interest, to be calculated from the date of claim rejection until payment.
Additionally, the company was directed to pay Rs 5,000 for deficiency of service, Rs 5,000 for the pain caused, and Rs 5,000 as litigation costs, all within 45 days from August 11.