Vishal.Patadiya@timesofindia.com
Surat: Surat district consumer disputes redressal commission (Additional) has directed an insurance company to pay a medical insurance claim of Rs. 5.52 lakh to the family of a 15-year-old girl, ruling that the insurer failed to prove its allegation that the injuries resulted from an attempted suicide. The girl had suffered serious injuries after her dupatta became entangled around her neck while she was playing, but the insurer rejected the claim, treating the incident as intentional self-harm, which was excluded under the policy.According to the complaint, the family had purchased a mediclaim policy with a coverage of Rs. 6 lakh for the period from Nov. 17, 2017, to Nov. 16, 2018. During the policy period, on Dec. 31, 2017, the complainant’s 15-year-old daughter accidentally got her dupatta entangled around her neck while playing. She sustained neck injuries and developed other health complications. She was admitted to a private hospital, where she remained under treatment until Feb. 16, 2018. The total medical bill amounted to Rs. 5.52 lakh.When the family submitted the insurance claim, The Oriental Insurance Company Ltd rejected it on March 23, 2018, citing the policy exclusion for intentional self-injury or suicide attempts. The family then approached the Surat CDRC (Additional) on June 27, 2019, alleging deficiency in service and unfair trade practice, and sought reimbursement of the medical expenses.The insurance company argued that the complainant had failed to establish that the dupatta became entangled accidentally. It contended that no police records, medico-legal case (MLC) documents or other evidence explaining the circumstances of the incident had been produced. According to the insurer, this raised doubts about the nature of the incident, making it ineligible for coverage under the policy. The company also pointed to a medical record mentioning “cervical hanging at her home at around 8 pm”, claiming that this suggested the injuries were not accidental.After hearing both sides, the commission observed that the insurance company had failed to produce any evidence to substantiate its allegation of attempted suicide or intentional self-injury. It held that mere assertions without supporting proof could not justify rejection of a genuine insurance claim.Holding the insurer guilty of adopting an unfair trade practice, the commission directed it to pay the claim amount of Rs. 5.52 lakh along with 7% annual interest from the date of claim rejection. It also awarded the complainant Rs. 5,000 towards compensation for mental harassment and litigation expenses.
