The District Consumer Disputes Redressal Commission-2 in Chandigarh has reprimanded Aditya Birla Health Insurance for unjustly denying a policyholder's claim. The court mandated the insurer to reimburse ₹54,228 for medical expenses and pay an additional ₹15,000 as compensation for mental harassment and legal costs.
Case Background
Sanjeev Rana, a resident of Sector 38 West, Dadumajra, had purchased the Active Assure Diamond health insurance policy from Aditya Birla Health Insurance, offering coverage up to ₹5 lakh. In April 2024, he was hospitalized at Max Super Specialty Hospital, Mohali, due to severe dehydration and elevated creatinine levels. The hospital submitted a claim for the incurred medical expenses. However, the insurance company rejected the claim, asserting that the hospitalization was unnecessary and could have been managed on an outpatient basis.
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The consumer court found the insurer's rejection of the claim to be arbitrary. It emphasized that the treating physician is the sole authority to determine the necessity of a patient's admission. The court noted that insurance companies often accept premiums readily but resort to unreasonable excuses when claims are filed.
The commission, led by Chairman Amarinder Singh Sidhu and member Brij Mohan Sharma, ordered Aditya Birla Health Insurance to:
Reimburse ₹54,228, representing the medical expenses incurred by Sanjeev Rana, along with interest.
Pay ₹15,000 as compensation for mental anguish and legal expenses.
The insurer was directed to comply with the order within 60 days.
