A child born after obtaining a family health insurance scheme is not covered by the policy, the Maharashtra State Consumer Dispute Redress Commission held recently and rejected a plea filed by a Goregaon-based Chartered Accountant for reimbursement of expenses he incurred in treating his Second Child.
The Complainant, Rishikesh Agarwal, had taken out a family floating health insurance policy in the year 2014 – 15 for the insurance coverage of ₹7,000,000. The policy has been offered as a group insurance policy for all Chartered Accountants as members of the Institute of Chartered Accountants of India and renewed from time to time.
The complainant purchased the policy for himself, his wife and approximately four year old son. Ten months after the policy underwriting, the couple had a second child born on February 16, 2015. The little boy had to be transferred to the neonatal intensive care unit of Surya Hospital in Santacruz (west) shortly after his birth. birth. The child was under treatment for two months and was discharged on April 17, 2015. The complainant had to pay ₹6.28 lakh for medical expenses.
The complainant then approached the insurance company, asking them to reimburse the expenses he had incurred for the treatment. Her claim request was denied by the company, saying the newborn was not covered by the policy. Therefore, in 2015, he approached the Consumer Dispute Redress Commission of the Southern District of Mumbai and sought reimbursement of expenses under the policy, claiming that children up to the age of 25 years were covered by the group policy for his parents.
He moved the state commission after the district commission in 2018 dismissed his complaint, saying he was not entitled to the claim amount.
The state commission recently upheld the district commission’s order. He stated that the complainant’s first policy covered the period from April 11, 2014 to April 10, 2015. It was renewed for a further period of one year from April 11, 2015 and, in both policies, coverage of assurance was granted to the complainant, his wife and his wife. her four-year-old son – Daksh. “There is no reference in the policy that during the term of the policy the complainant’s newborn child would have insurance cover. In fact, no premium was paid by plaintiff for his newborn child,” the state commission said.
“There is no contract between the plaintiff and the opponent to cover the newborn child for the duration of the policy”, he added and rejected the appeal lodged by the accountant .