Star Health And Allied Insurance — insurance company has denied claim and not willing to share evidence on which the claim is rejected.

Address:

NO.1,NEW TANK STREET,VALLUVARKOTTAM HIGH ROAD, NUGAMBAKKAM CHENNAI, Chennai, Tamil Nadu, TN 600034

Mr pradeep manjrekar (Father) got admitted in the hinduja hospital with diagnosis of infected left knee joint. He is suffering from this aliment since 2019. Patient is covered in corporate mediclaim policy since[protected]. The policy period is[protected] to[protected]. As per policy terms and condition pre-existing diseases are covered. There is no waiting period for pre-existing disease. Patient underwent the total knee replacement surgery in the year 2019 as per policy terms and condition there is an aliment capping for knee replacement surgery during the policy period. Insurance company while processing the claim for infected knee joint applied an aliment capping for knee replacement surgery which is not justified.
Patient is suffering from infected knee joint. Patient underwent multiple debridement’s with external fixator application and left knee arthrodesis in hinduja hospital. Since the treatment was for infected knee joint and the same did not figure among the ailment capping diseases, it was understood that the patient could not be faulted for interpreting the condition in the aforesaid manner and thereby staking his claim for reimbursement of the entire medical expenses.
Patient admitted and underwent treatment for infected knee joint and not for knee replacement surgery (This has been confirmed by doctors and test reports, same was shared with insurance company on the very same day). As documentary evidence had proved this point, the insurance company’s restriction to the aliment capping is questionable.in the facts and circumstances the decision of the insurance company to settle the claim of infected knee joint for rs. 150, 000/- is not acceptable.
Any contract of insurance, to be enforced, has to necessarily be based on the principle o[censored]berrimae fides, i. E. Utmost good faith.in an insurance contract, the intention of the parties must prevail, and this intention is to be looked for in the policy itself.in the absence of any specific condition mentioned on the schedule of the policy limiting the sum insured to rs. 150, 000/- for the treatment of infected knee joint, the patient cannot be found fault with for having interpreted the terms of contract as those literally mentioned on the face of the policy.