INSURER CANNOT DECIDE IF HOSPITALIZATION IS REQUIRED OR NOT

FACTS

IN YEAR 2022, A PERSON WAS ADMITTED TO HOSPITAL IN NOIDA AFTER SUFFERING FROM HIGH FEVER AND FACING BREATHING DIFFICULTY. THEY ALSO INFORMED THE INSURANCE COMPANY IN ADVANCE FROM WHERE THE PERSON WAS HAVING HIS MEDICLAIM POLICY. THE COMPANY ASSURED THAT CASHLESS CLAIM WILL BE CLEARED IN FEW DAYS. WHEN THE TREATMENT WAS DONE, THE INSURANCE COMPANY REJECTED THE CLAIM. LATER, THE PARTY WAS FORCED TO PAY THE BILL ON THEIR OWN. AFTERWARDS THEY FILED A CLAIM FOR REIMBURSEMENT WITH THE INSURANCE COMPANY. IT WAS ALSO REJECTED WITH REASONS THAT THERE WAS NO NEED FOR THE PATIENT TO GET ADMITTED FOR A SIMPLE FEVER WITHOUT HAVING OTHER SYMPTOMS.

AGGRIEVED BY THE SAME, THE PERSON SENT THEM A LEGAL NOTICE, HOWEVER STILL CLAIM WAS NOT PASSED. LATER A CONSUMER CASE HAS BEEN FILED AGAINST THE INSURER.

OBSERVATIONS

RECENTLY WHILE PASSING THE JUDGMENT, THE CONSUMER FORUM OBSERVED THAT IN SUCH CASES, THE INSURER CANNOT DECIDE IF THE PATIENT REQUIRES ANY HOSPITALIZATION OR NOT. IF THE DOCTORS ADVISE THAT PATIENT IS TO BE TREATED IN HOSPITAL, THEN THE INSURER CANNOT THE CHALLENGE THE SAME.

THEREFORE, THE INSURER WAS DIRECTED TO REIMBURSE THE CLAIM AMOUNT OF RS. 50,000/- ALONG WITH INTEREST AND LITIGATION COST.

I HOPE THE INFORMATION SHARED HERE WILL BE HELPFUL FOR THE ASPIRANTS. FOR ANY FEEDBACK, PLEASE FEEL FREE TO SHARE YOUR COMMENTS.

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