A health insurance company cannot invoke a waiting-period condition to turn down a hospitalisation claim for a medical condition that is not covered by the policy's specified exclusions. The Delhi State Consumer Disputes Redressal Commission underscored this while rejecting HDFC ERGO General Insurance's appeal against a consumer court order that had directed the insurer to compensate a policyholder whose dengue treatment claim was denied, reported The Economic Times.
The controversy arose after HDFC ERGO refused cashless treatment and later rejected the ₹17.99 lakh reimbursement claim, citing a 24-month waiting period prescribed for certain illnesses and medical procedures, including treatment for prolapsed intervertebral disc (PIVD), a spinal disc disorder. However, the policyholder, Mr Kumar, had been admitted to hospital for dengue fever, a condition not mentioned in the relevant list of exclusions.
Finding that the waiting-period provision could not be applied to his diagnosis, the State Commission upheld the District Consumer Commission's order on October 6.
What happened?
The dispute originated in November 2019, when Kumar tested positive for dengue fever on November 2. Acting on medical advice, he was admitted to Max Super Speciality Hospital in Patparganj, Delhi, on November 3.
HDFC ERGO turned down his request for cashless treatment on November 6. Kumar then transferred to another Max Super Speciality Hospital in Vaishali, hoping to continue treatment there. However, his second cashless authorisation request was also rejected on November 12. He remained hospitalised until November 21.
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