A consumer commission directed Care Health Insurance to reimburse a Dera Bassi woman ₹ 74,000 for hospital treatment and ambulance charges after holding that the insurer wrongly rejected her claim by invoking a 24-month waiting period for spinal disorders despite her account of an accidental fall.
An MRI of her lumbosacral spine showed disc-related abnormalities. She argued that the treatment followed an accident and that the insurer should have considered her previous insurance coverage while calculating the waiting period. The insurer maintained that the claim concerned disc sequestration and a chronic spinal disorder covered by the waiting-period clause. It relied on a second medical opinion to support its decision. The commission held that the insurer’s subsequent rejection, after initially approving cashless treatment, amounted to deficiency in service.
She developed severe pain after falling from her bed on September 28, 2022, and was taken by ambulance to Alchemist Hospital, according to the complaint. The hospital sought cashless treatment authorisation, which the insurer initially approved for ₹ 33,000 before withdrawing it on the ground that spinal disorders carried a 24-month waiting period. Lata was discharged against medical advice on October 3, 2022, after incurring medical expenses of ₹ 72,375. She also paid ₹ 2,000 for the ambulance.
