3 weeks ago
Father wins Rs 94,000 after insurer rejected child's hospitalisation claim
A boy named Agam got very sick with a high fever and a sore throat and had to stay in the hospital for several days.
His doctors gave him fluids and antibiotics to help him get better.
The hospital treatment cost a lot of money, about Rs 58,729.
Agam's family had a health insurance policy that was supposed to help pay for hospital costs.
But the insurance company said the hospital stay was not really needed and refused to pay.
Agam's father did not give up.
He took the insurance company to a special consumer court.
The court looked at all the records and the doctor's certificates.
The court said that only doctors, not insurance companies, can decide if a patient needs to stay in the hospital.
The court told the insurance company to pay for the treatment, plus extra money as a penalty.
In the end, the family won the case and got about Rs 94,000.
The Kangra District Consumer Disputes Redressal Commission ruled that Star Health's rejection of a child's hospitalisation claim was 'completely wrong, illegal' and a deficiency in service.
Gurdeep Singh's son Agam was hospitalised from August 12-17, 2023, with high fever, severe throat pain, thrombocytopenia (low platelet count) and transaminitis (high liver enzymes).
Star Health rejected the Rs 58,729 claim on September 20, 2023, arguing under policy exclusion Code Excl 36 that hospitalisation was not medically necessary.
The commission held that the treating doctor, not the insurer's in-house medical team, decides whether a patient needs hospitalisation, and noted Star Health filed no supporting medical affidavit.
The insurer must pay Rs 58,729 with 9% annual interest, plus Rs 20,000 compensation and Rs 15,000 litigation costs, totalling about Rs 93,729.
- Who
- Gurdeep Singh, a father from Kangra, Himachal Pradesh, who filed a complaint against Star Health and Allied Insurance Company Limited over his son Agam's rejected claim.
- What
- The consumer commission ordered Star Health to reimburse the treatment cost plus compensation and litigation costs, ruling the claim rejection illegal.
- Where
- Kangra district, Himachal Pradesh, after treatment at Zonal Hospital, Dharamshala, and City Hospital, Matour, Kangra.
- When
- The boy was hospitalised from August 12 to 17, 2023; Star Health rejected the claim on September 20, 2023; the commission delivered its order on July 29 (year not stated in the article).
- Why
- The commission ruled that the treating doctor's decision to hospitalise the child stands, and an insurer cannot override it based solely on an internal medical assessment.
Patient / Consumer side
Insurer side
Who decides hospitalisation necessity
Patient / Consumer side
The treating doctor who certified hospital treatment was required should decide, and the insurer's repudiation on medical grounds is wrong, illegal and a deficiency in service.
Insurer side
The insurer's in-house medical team scrutinised the records and concluded the patient could have been treated as an outpatient, so hospitalisation was not warranted under policy exclusion Code Excl 36.
Value of medical expenses
Patient / Consumer side
Bills produced by the complainant totalling Rs 58,729 accurately reflect the treatment cost.
Insurer side
An unsigned bill assessment sheet showed the expenses amounted to Rs 33,727, not Rs 58,729.
Key facts
- Commission
- Kangra District Consumer Disputes Redressal Commission
- Complainant
- Gurdeep Singh
- Insurer
- Star Health and Allied Insurance Company Limited
- Policy
- Family Health Optima (bought 2021, renewed through August 11, 2024)
- Diagnosis
- Acute fever with thrombocytopenia and transaminitis
- Hospitalisation period
- August 12-17, 2023
- Treatment cost
- Rs 58,729
- Total award
- Rs 58,729 + 9% annual interest, Rs 20,000 compensation, Rs 15,000 litigation costs (about Rs 93,729)
Sources
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