Ahmedabad: A consumer disputes redressal commission has held that an insurance company cannot decide whether a patient requires hospitalisation, observing that such a decision rests solely with the treating doctor. The commission made the observation while directing an insurer to settle mediclaim claims rejected on the ground that hospitalisation was unnecessary.
In one case, Navrangpura resident Rajanikant Mehta was admitted to a hospital for a day in March 2023 after experiencing excessive perspiration and a blackout. He was diagnosed with hypothyroidism and discharged the following day after incurring medical expenses of about Rs 70,000. In another case, Isanpur resident Jaiprakash Singh sought reimbursement of Rs 58,000 spent on eye treatment after suffering severe headaches.
The insurer argued that the hospitalisation was only for diagnosis and evaluation, that there was no active line of treatment, and that the patient stayed in hospital for a day merely to claim medical expenses. Rejecting the contention, the commission observed, “Whether the stay in the hospital was necessary or not is to be decided by the treating doctor as per the requirement of the patient. The opponent insurance company cannot decide whether the patient should be hospitalized or not and so the opponent has failed to justify the repudiation of the claim of the complainant. The insurer rejected the claim, citing an exclusion clause and contending that neither the hospitalisation nor the procedure was covered under the policy’s day-care treatment list. “The treating doctor has adopted the ‘Yag Laser PI’ procedure for the treatment of the complainant as the doctor found it fit for the complainant. It is absolutely the decision of the treating doctor to decide the hospitalization and not the insurance company,” the commission’s order reads.