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A child born after obtaining a family health insurance plan is not covered under the policy, the Maharashtra State Consumer Disputes Redressal Commission held recently and dismissed a plea filed by a Goregaon-based chartered accountant for reimbursement of the expenditure that he had incurred on treating his second child.
The complainant, Rishikesh Agarwal, had purchased a family floater mediclaim policy in the year from 2014 – 15 for insurance cover of ₹7 lakh. The policy was offered as a Group Insurance Policy for all the chartered accountants as members of the Institute of Chartered Accountants of India and renewed from time-to-time.
The complainant had taken the policy for himself, his wife and son aged about four years. Ten months after the purchase of the policy, the couple had a second child born on February 16, 2015. The baby boy had to be shifted to the neonatal intensive care unit at Surya Hospital in Santacruz (west) soon after his birth. The child was under treatment for two months and was discharged on April 17, 2015. The complainant had to pay ₹6.28 lakh towards the medical bills.
The complainant then approached the insurance company, asking them to reimburse the expenses that he had incurred for the treatment. His claim request was rejected by the company claiming that the newborn baby was not covered under the policy. Hence, in 2015, he approached the South Mumbai District Consumer Disputes Redressal Commission and sought reimbursement of the expenditure under the policy, claiming that children upto the age of 25 years were covered under the group policy for his/her parents.
He moved the state commission after the district commission in 2018 dismissed his complaint, stating that he was not entitled to the claim amount.
The state commission recently upheld the district commission order. It said the complainant’s first policy was for the period 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 insurance cover was given to the complainant, his wife and his four years old son – Daksh. “There is no reference in the policy that during pendency of the policy, the newborn child of the complainant would be given insurance cover. In fact, no premium was paid by the complainant for his newly born child,” said the state commission.
“There is no contract between the complainant and opponent to give cover to the newly born child during pendency of policy,” it added and dismissed the appeal filed by the chartered accountant.
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