Court orders Star Health Insurance to pay Rs 35,000 to customer for rejecting viral fever claim

The Ludhiana District Consumer Disputes Redressal Commission has ruled in favor of a customer whose son's hospitalization claim was rejected by a health insurance company. As per a TOI report, the commission has ordered the insurance company, Star Health and Allied Insurance Company, to pay Rs 10,000 to the customer, Ashok Aggarwal, after it denied his claim for his son's treatment for viral fever and thrombocytopenia (low blood platelet count).

Additionally, the commission has directed the insurance company to pay the approved amount of Rs 24,497, as per the bill assessment sheet, to Aggarwal within 30 days. In case of default, the company will be liable to pay an interest of 8% per annum.

According to the complaint, Aggarwal had availed a 'family floater' insurance policy from the firm, covering himself, his wife Asha Aggarwal, and their son Mohit Aggarwal. Mohit was admitted to a city hospital from November 29 to December 1, 2019, where he received treatment for viral fever and thrombocytopenia. Aggarwal incurred expenses amounting to Rs 25,896 for his son's treatment, which he had to pay himself as the hospital was not listed with the insurance company. He filed a reimbursement claim on December 7, 2019, but it was rejected by the insurance company on unsubstantiated grounds.


Aggarwal alleged that the rejection of his claim was illegal and arbitrary, causing him mental agony and harassment. He served a legal notice to the insurance company, but received no response. Consequently, he approached the consumer forum, seeking reimbursement of the entire claim amount, along with a compensation of Rs 1 lakh and litigation expenses of Rs 22,000.

The insurance company argued that their medical team, upon reviewing the claim file, found that the insured patient's condition was stable throughout the hospitalization period. Based on this observation, they believed that outpatient treatment would have sufficed and hospitalization was unnecessary.

The commission, however, noted that the insurance company failed to provide any expert medical opinion or affidavit from their medical team to support their contentions. After examining the evidence, the commission concluded that the complainant's claim appeared to be genuine and not false or fraudulent.