Holding Star Health & Allied Insurance Company Ltd guilty for not providing privileged facilitation in medicare for a senior citizen, the national consumer disputes redressal commission (NCDRC) directed the insurer to reimburse Rs3.20 lakh with 10%pa (per annum) and Rs1 lakh litigation costs. The insurer is also asked to deposit punitive charges of Rs2 lakh in the legal aid account of the Odisha state consumer disputes redressal commission.
In
an order last week, the NCDRC bench of Subhash Chandra (presiding member) and Dr Sadhna Shanker (member) said, "In the instant case, not only did Star Health & Allied Insurance fail to provide privileged facilitation in medicare for senior citizens despite promising to do so through a policy promoted on such a promise, it is also liable for deficiency in service for rejecting a claim for cashless admission in the hospital based on a co-payment basis as per its own terms and conditions by linking it to documents that were not relevant when the policyholder was admitted in the intensive care unit (ICU), but also subsequently insisting on such documentation at the stage of reimbursement."
However, as the award of Rs15 lakh including reimbursement of medical expenses, compensation, punitive damages and costs by the state commission is concerned, the bench says, while it is manifest that the insurer is liable for both unfair trade practice and deficiency in service, it considered it appropriate to modify the order to set aside the Rs15 lakh compensation, Rs5 lakh as punitive damages and Rs25,000 towards costs.
In April 2016, Bhubaneswar-based Ranjan Mohapatra bought a Rs10 lakh senior citizens red carpet health insurance policy from Star Health & Allied Insurance and paid Rs25,575 as a premium. Under the scheme, Mohapatra, a senior citizen was declared as suffering from diabetes and hypertension as pre-existing diseases and was eligible for treatment, including hospitalisation, subject to terms and conditions.
On 10 January 2018, he was admitted to the ICU in Apollo Hospital in Bhubaneshwar with a fever with a diagnosis of diabetes mellitus, lobar pneumonia and dilated cardiomyopathy (DCM). Mr Mohapatra applied for pre-authorisation for the cashless facility of treatment under his insurance policy.
Star Health & Allied Insurance asked him to submit details of past hospital discharge from SAAOL Heart Centre on 21 May 2016 with the duration of treatment of chronic obstructive pulmonary disease (COPD) and rheumatoid arthritis (RA) and a statement from the treating consultant along with past treatment details and first prescription and investigation reports including x-ray, PFT, blood reports and temperature chart.
On 12 January 2018, the insurer asked Mr Mohapatra to submit a letter from the treating doctor clarifying when COPD and RA were diagnosed. On 16 January 2018, Star Health & Allied Insurance rejected the pre-authorisation for cashless treatment. Further, when Mr Mohapatra submitted a reimbursement claim, it was also rejected by the insurer.
Mr Mohapatra then filed a complaint before the state commission. In its order on 8 July 2022, the state commission directed Star Health & Allied Insurance to pay Mr Mohapatra Rs3.20 lakh as hospitalisation charges, Rs15 lakh towards compensation, Rs5 lakh as punitive damages and Rs25,000 towards costs.
Aggrieved by the order, Star Health & Allied Insurance approached NCDRC. It argued that under the terms of the policy, cashless treatment was available to policyholders under the 'co-payment' clause which required payment of 50% of the bill for existing diseases and 30% of each claim for all other claims. It contended that it acted as per the policy and sought details of previous treatment and hospitalisation which was not provided and therefore the cashless facility and subsequently the reimbursement was not approved.
The counsel for Mr Mohapatra contended that the argument of the insurer is unfounded since the pre-authorisation for cashless treatment was rejected on superfluous and arbitrary grounds that it was not possible to establish the duration of COPD and RA which was not related to Mr Mohapatra’s condition for which he was admitted to the hospital.
"Mr Mohapatra was suffering from COPD and RA was incorrect as he had no such medical history and was therefore unrelated to the processing of the claim for hospitalisation and subsequently reimbursement. Mr Mohapatra had been admitted to the hospital on account of high fever, chills and rigours in an emergency situation and was admitted to the ICU being a senior citizen aged 67 years and, in view of his vulnerable state with no support except his wife, he had requested for cashless facility," the counsel submitted.
The NCDRC bench observed that the senior citizens’ red carpet health insurance policy was designed for senior citizens. "The policy had features that were designed to factor in the special requirements of diseases and illnesses that afflict the aged. It was further marketed as a ‘red carpet’ policy that connoted that it would provide special and expedited services as the policyholder belonged to a special class of (senior) citizens through a heightened sensitivity to their requirements. It also conveyed that the service under the policy would be as provided to privileged customers as connoted through the moniker ‘red carpet’."
"The facts of the case on hand, however, indicate that Star Health & Allied Insurance as the insurer delayed and thereafter denied pre-hospitalisation authorisation by insisting on the production of documents pertaining to a treatment availed two years prior. It has not been established by the insurer how the documents sought were material to the hospitalisation of Mr Mohapatra. If he had been admitted for RA and COPD in Apollo Hospital, the requisitioning of the documents would have been germane to the processing of the case by Star Health & Allied Insurance. In the absence of any documents being brought on record to support this, the contention of Mr Mohapatra that these were unnecessarily being sought to deny him the facility of cashless treatment in the hospital thereby gets credence," NCDRC says.
While modifying the state commission's order, the bench directed Star Health & Allied Insurance to pay Rs3.20 lakh with 10%pa interest, and Rs1 lakh litigation costs.
(First Appeal No668 of 2022 Date: 4 September 2024)
Their cheating business must be stopped
Wating period also over. After one month hectic follow up, they asked me to go court.on Rs.1lakh 38
thousand claim they denied fully
..no help...these frauds like Starhealth will thrive and prosper
A local senior citizen inhabitant may feel comfort in staying at home complying to tests ordered by the diagnostic specialist doctor, in the next few days, and then come back.
In such a case, the Star Health or any other health insurance company should apply thought (instead of incomplete and biased rule) and should consider allowing charges spent for consultation, diagnostic reports, and medicines.
In my experience, it didn't happen.
One must stay in hospital for at least overnight or 24-hours, before becoming eligible for attention from health insurance provider. Please look into this and rectify after examining case-by-case basis.
I hope to give my sincere thanks to whoever is eligible over this comment / feedback.
Also, "cashless" treatment is a myth.
My wife however got her medical reimbursement from another insurer.
This company is not setteld claim.
Buy any insurance company but not starhelth
Hope I will get justice
They are rejecting the claims.