Star Health rejected Insurance Claim of Woman citing Menstrual Bleeding Reason, Court order compensation

The District Consumer Disputes Redressal Commission in Malappuram, led by Sri. Mohandasan K (President), Smt. Preethi Sivaraman C (Member), and Sri. Mohamed Ismayil C.V (Member), found Star Health & Allied Insurance Company Limited liable for deficiency in service and unfair trade practice due to their denial of an insurance claim. The Commission emphasized that menstrual bleeding is a natural biological process for women.

Case Details

The complainant, Mr. Sathynathan, purchased a family insurance policy from Star Health & Allied Insurance Company Limited on October 9, 2020, for a coverage amount of Rs. 4,00,000 under policy number P/181312/01/2023/006993. He paid a premium of Rs. 14,989 and renewed the policy annually. Mr. Sathynathan claimed he acquired the insurance policy based on assurances from the second opposite party (agent) that he could benefit from coverage up to Rs. 4,00,000 per year.

He indicated that no medical examination was conducted for him or his family members when the policy was issued. His wife got admitted in hospital for treatment of urinary tract infection. The claim for Rs. 1,07,027 was initially approved but later cancelled.

Star Health & Allied Insurance Company Limited said that a request for cashless hospitalization was made from NIMS Hospital, Malappuram, where the complainant’s wife was diagnosed with a urinary tract infection/cystitis on June 25, 2023. The discharge summary revealed a diagnosis of left tubo-ovarian mass with abscess, alongside other conditions. The insurance company initially approved Rs. 1,07,027 based on the provided documents.

However, they later pointed out that the hospital records indicated a history of abnormal uterine bleeding as early as 2018, which was not disclosed in the insurance policy application form. Company said that his wife had consulted a doctor as an outpatient in 2018 which means that she had this medical issue before the start of policy. This omission was cited as the reason for the claim’s repudiation.

What Commission said?

The Commission observed that the policy was initiated in 2020, while the outpatient consultation took place in 2018. They noted that no evidence indicated treatment during the policy period. The Commission highlighted that the complainant’s wife, aged 42, consulted a doctor for a bleeding issue, which should not be categorized as an ailment. They reiterated that menstrual bleeding is a natural biological process. Given that the insurance company had initially approved the claim, the Commission found them responsible for deficiency in service and unfair trade practice.

The Commission ordered Star Health & Allied Insurance Company Limited to pay Rs. 1,07,027 as the insurance claim amount to the complainant, along with Rs. 50,000 as compensation for deficiency in service, and Rs. 10,000 to cover the costs of the proceedings.

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