Star Health & Allied Insurance Asked To Pay Rs15.30 Lakh towards Hospital Expenses, Costs
Moneylife Digital Team 12 October 2023
Rejecting the contention of Star Health & Allied Insurance Co Ltd about concealment of pre-existing disease, the national consumer disputes redressal commission (NCDRC) directed the insurer to pay Rs15 lakh as expenses for medical treatment and Rs30,000 costs. 
 
In an order, the NCDRC bench of Subhash Chandra (presiding member) and air vice-marshal (AVM) J Rajendra (retd) (member) says, "It is in common amongst children of tender age to have convulsions during high fever conditions and recover after high temperature recedes. Therefore, a mere isolated event of such an incident cannot constitute knowledge of an entirely independent medical condition that may be revealed at a subsequent stage. The stated facts and records reveal that, while the complainant clarified the circumstances under which he discovered the medical condition of his child, Star Health & Allied Insurance failed to establish that the child was suffering from this disease by birth and there was concealment of fact at the time of taking the insurance policy. Therefore, the claim is liable to be allowed."
 
Lucknow-based Atul Kumar Rai bought a health insurance policy for himself, his wife and his son from Star Health & Allied Insurance after paying a premium of Rs18,719. The Rais received identity cards from the insurer; however, no policy document was issued. The policy was renewed every year between 28th February and 27 February 2018. 
 
In June 2016, Mr Rai noticed some spots on his son's back and consulted Medanta Global Health Pvt Ltd. The medical examination revealed the presence of café-au-lait spots and a tuft of hair on his back. After that, an electroencephalogram (EEG) and magnetic resonance imaging (MRI) were conducted, and the impression was diagnosed as neurofibromatosis. On 13 July 2016, Mr Rai subsequently consulted Primus Super Specialty Hospital, and after confirming the child's condition, surgery was advised. He requested cashless treatment at the hospital, which was denied by the insurer, leading to him spending Rs14.75 lakh in Primus Super Specialty Hospital and Rs29,510 in Medanta Global Health.
 
He contacted Star Health & Allied Insurance for reimbursement and submitted all required documents. However, the claim was rejected without clear communication. Mr Rai alleged that the rejection was arbitrary and violated the principles of natural justice. 
 
Mr Rai alleged that this disease was not a genetic or birth defect, as it was not present in any family member, and he only became aware of it during the consultation at Medanta Global Health Hospital. The insurance policy's terms and conditions did not exclude pre-existing conditions, and he believes the denial of the claim by the insurer is unjust.
 
Being aggrieved by the repudiation of mediclaim and deficiency in service on the part of Star Health & Allied Insurance, he filed a consumer complaint before the Uttar Pradesh state consumer disputes redressal commission. He also prayed to continue the health policy or health insurance of his son. He also prayed that the insurer be directed to pay Rs15.05 lakh spent on the treatment and Rs34 lakh towards mental agony and harassment.
 
In its response, Star Health & Allied Insurance denied Mr Rai's claim, stating that they issued a star comprehensive insurance policy covering Mr Rai, his wife and son for Rs7.50 lakh. The insurer asserted that Mr Rai failed to disclose the pre-existing disease of his son in the proposal form. Consequently, the insurer repudiated the claim vide letter on 20 March 2017 and cancelled the policy of the child from 27 May 2017, in terms of condition no14 of the policy and refunded Rs3,852. 
 
Star Health & Allied Insurance further contended that café au lait macules is a type of birthmark present since the insured child's birth. These marks, characterised by hyper-pigmented skin patches with sharp borders and diameters of less than 0.5cm (centimetres) , are considered congenital anomalies. They can be present at birth or appear in early infancy, sometimes associated with systemic diseases. As per the insurer, the insured child has had these marks since birth. The insured child was two years and six months old at the policy's inception, and the Rais were aware of it. The insurer contended that the failure to disclose this significant medical history in the proposal form amounted to misrepresentation and non-disclosure of material facts, violating condition number nine of the insurance policy.
 
However, the state commission rejected the contention by the insurer and asked Star Health & Allied Insurance to pay Rs15 lakh towards hospital charges with an interest of 6%pa (per annum), Rs5 lakh for mental agony, harassment and Rs20,000 as cost of litigation. It also directed the insurer to extend the term of the policy till its validity for the child.
 
Star Health & Allied Insurance challenged the order before NCDRC. 
 
During the hearing, the Rais contented that the history of febrile seizure mentioned in the discharge summary from Primus Super Specialty Hospital is unrelated to the café-au-lait spots, and the insurer has misinterpreted this medical history. "The disease in question is neither genetic nor present at birth. Neither the parents nor any family members had such a history. They first became aware of their son's condition during a consultation at Medanta Global Health Hospital. Star Health & Allied Insurance unjustly and arbitrarily rejected the claim and condition no14 of the policy cited does not apply to the case."
 
The counsel for Star Health & Allied Insurance argued that after an MRI on 12 July 2012 and further episodes of febrile convulsion and antiepileptic treatment of the child, Mr Rai realised expensive future treatment and obtained insurance on 28 February 2014 for himself, his wife and child, deliberately concealing the medical condition of the child. He signed a proposal form on 28 February 2014 misrepresenting material facts and misleading the insurers relating to the child that he was in good health and free from physical and mental disease or infirmity; no consultation, treatment and admission for any illness was done, the counsel added.
 
After hearing both sides, examining the pleadings and going through associated documents placed on record, NCDRC observed that there is no dispute about the existence of the policy, the medical condition of the child, treatment given to the child, as well as the amount of claim that Mr Rai preferred to the insurance company. "The whole controversy thus revolves around the fact whether the child's medical condition was at the stage of his birth and was it known to Mr Rai, who failed to inform Star Health & Allied Insurance while making a proposal for insurance."
 
The bench says it is a fundamental principle in the insurance contracts that the party claiming the exemption clause needs to establish the same. "However, Star Health & Allied Insurance failed to substantiate that the insured child had such a medical condition by birth and that, while being aware, the complainant failed to notify the same to insurer the stage of making the proposal. On the other hand, the complainant, the father of the child, repeatedly asserted the absence of knowledge of such medical condition, if any, and that the first discovery of the same was made much after the insurance contract was entered into and, therefore, he is entitled to reimbursement of medical expenses under the scope of the policy."
 
The bench directed Star Health & Allied Insurance to pay Rs15.30 lakh to Mr Rai. It also set aside the Rs5 lakh compensation awarded by the state commission for mental agony and harassment. 
 
(First Appeal No150 of 2021  Date: 9 October 2023)
 
Comments
bigzook.in
4 months ago
Star health is the biggest scam in health sector, they have lot of terms and conditions Im suggesting to take hdfc ergo which take some extra money but it has real use case , spending 2-3 thousand extra is more benificial, before taking any health policy first compare it on youtube then go for any health policy
Thanks
findmeassai
4 months ago
Same happened to my wife. I have been with star health for so long . Yet at certain moment when we raised the cashless. They just rejected it without any intimation. And the customer executive is too bad. That they want to take all the original documents to the status health office in person. Complete bad experience for me so I ported from start health and thought of never going back again..
mangaldeshraj0
4 months ago
My claim is pending with Star Health Allied Insurance company from 11.10.23 and send so many emails but not responding even a mail is also sent to their CMD but no response.This is highly objectionable and negligence on their part.
mastan.penchalliah
4 months ago
Similar incident happened to me though I was informed of my previous surgery the agent hid that for getting his targets to reach and finally they denied my hospitalization charges

Oone of the biggest fraud insurance company
bps6918
Replied to mastan.penchalliah comment 4 months ago
Bilkul sahi hai star health mein ullu banane ka Kam hai koi bhi star health insurance Naa karaye.
Kamal Garg
4 months ago
With so much of bad experience of the people and mishandling on the part of Star Health to the insured ones, I think, time has come where IRDAI has to intervene. And the solution does not lie in cancelling the licence because if you cancell the licence, all hapless insured ones would be affected because their policies would become null and void (even if an alternate insurance companiy is provided by IRDAI to switch).
shripsacharya
4 months ago
???? ?? ???? ?? ?? ?????????? ?????? ?? ????? ???? ! ???? ?????? ????? ??? ????? ???????? ??? ? ????? ???? ?? ???????? ??????? ??? ???? ???????? ?? ?? ??? ???? ?? ??? ?? ?? ???? ?????????? ????? ???? ???? ???? ?? ??? , ?? ?? ??? ???? ?? ?? ?? ????? ????? ????? ??? ?? ?? ???? ????? ????? ??!
redmi404609
4 months ago
Star is a Golden Star. Star should give OPD bills from 01.11.2023 then I will praise it even more by naming it as a Platinum Star, yes , true, agreed with me , thanks. 16.10.2023, Monday 08:28:37 hrs.
pankajmbharati
4 months ago
They offer the cheapest premiums and people fall into their trap
pankajmbharati
4 months ago
I have heard that Star Health is doing this to lot of consumers and rejecting claims by making excuses very often
charanjeevkaurkeer
4 months ago
Kabhi yeh paper submit Karo kabhi doctor se likhwa ke lao yeh disease kab Hui iske proof do humare doctar ki team ke hisab se apki mom ko admit hone ki zarurat nhi thi kyuki koi organ failure nhi the.meams all rubbish
charanjeevkaurkeer
4 months ago
Yes yeh chor hain mere mom ke saath bhi aise kiye although she is widow unko bhi bahut harass kiye
priyeshdhaniya
4 months ago
Whatever the diagnosis by hospital, Star health will always rejected the claim by saying "It is pre-existing disease, which you didn't disclose in the policy". There pure intention is to Reject the claim whatever proof or document you submit. Even Doctor's mentioned prognosis specially highlight that the disease is not pre existing, they denied the fact and reject it. IRDAI must cancel there licence.
gafurb
Replied to priyeshdhaniya comment 4 months ago
That is it. In my case,Doctor had written a stern letter to them.
shripsacharya
Replied to gafurb comment 4 months ago
???? ??? ??? ???? ???? ??? ????? ???? ???? ?????? ???? ????? ???? ??? ?? ?????? ???? ?? ?????????? ?????? ??? ?? ?? ?????? ??? ????? ?? ?? ?? ?? ??? ?????? ! ???? ???????? ?? ???? ?????? ?? ?? ???????? ??! IRDAI ???? ??????? ????? ??????? ??? !
anil.marath
4 months ago
STAR and CARE........BEWARE
dipak.pattanayak
Replied to anil.marath comment 4 months ago
Is it worth to buy PSU insurance like new India,national, oriental instead of private as it is normally backed by govt so that genuine claims would settled by them hassle-free
myprasant0001
4 months ago
Star Health is chor company, even my 2claims are pending, even agents are nin cooperative n non responsible.
mjfinancialplanners
4 months ago
I had a bad experience for my reimbursement from star health we have taken insurance for bad time but star health make it worst now before 6 months I have filed consumer complaint in district consumer court 90% we have won but why star health make people fool
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