4 days ago
Delhi Consumer Forum Orders Insurer To Pay Emergency Treatment Claim
Arti Brar became unwell while visiting her daughter in the United States.
She went to an emergency room twice in three days.
Doctors performed tests and treated her symptoms.
The hospital bills together totaled $9,465.70.
Her travel insurer refused to pay, saying the hospital visits were mainly for testing.
A Delhi consumer commission disagreed with the insurer.
It said doctors, not insurance companies, decide what medical care is needed.
The commission ordered the insurer to pay the hospital costs plus compensation and legal expenses.
A Delhi consumer commission ordered an insurer to pay Arti Brar Rs 9,06,625 for emergency treatment received in the United States.
Brar visited hospital emergency rooms twice within three days after developing headache, fluctuating blood pressure, uneasiness and chest pain.
The insurer rejected the claim under an exclusion for admission primarily intended for investigation and evaluation.
The commission said treatment decisions belong to doctors and found the insurer guilty of deficiency in service and unfair trade practice.
The insurer must also pay Rs 25,000 for mental harassment and Rs 5,000 in litigation costs, with compliance due within 60 days.
- Who
- Arti Brar and her overseas travel insurer; the case was decided by the District Consumer Disputes Redressal Commission, South II, Delhi.
- What
- The commission ordered the insurer to pay Rs 9,06,625 for emergency treatment, plus Rs 25,000 for mental harassment and Rs 5,000 in litigation costs.
- Where
- The treatment took place at emergency rooms in the United States, and the case was decided in Delhi.
- When
- Brar travelled on January 1, 2023; she received treatment on January 28 and January 31, 2023. The commission issued its decision on September 18.
- Why
- The insurer rejected the claim under an investigation-and-evaluation exclusion, while the commission found that the hospital visits involved medically justified emergency treatment.
Consumer’s Case
Insurer’s Position
Whether the treatment was covered
Consumer’s Case
Brar argued that she required genuine emergency care after experiencing headache, blood-pressure fluctuations, uneasiness and chest pain, and sought reimbursement for the hospital bills.
Insurer’s Position
The insurer relied on a policy exclusion stating that expenses for admission primarily intended for investigation and evaluation were not covered.
Who decides the need for treatment
Consumer’s Case
The commission accepted that an insured person relies on the treating physician’s judgment and that Brar went to the nearest hospital after becoming unwell.
Insurer’s Position
The insurer did not appear before the commission and was proceeded against ex parte, so no further position from it was recorded in the proceedings.
Key facts
- Claimant
- Arti Brar
- Policy
- Overseas travel insurance valid through March 31, 2023
- Treatment
- Two emergency-room visits in the United States within three days
- Hospital bills
- $9,465.70 in total
- Ordered claim payment
- Rs 9,06,625, calculated at Rs 95.78 per US dollar
- Additional compensation
- Rs 25,000 for mental harassment and Rs 5,000 for litigation costs
- Compliance period
- 60 days; unpaid amounts carry 8% interest until realisation
Quotes
District Consumer Disputes Redressal Commission, South II, Delhi
The Delhi consumer commission hearing Arti Brar’s complaint against the insurer.
“It is a well-established principle that the choice of medical treatment lies exclusively within the professional discretion of the treating physician, and not within the purview of the insurance company.”
indianexpress.com
“Given these circumstances, it is implausible to suggest that hospitalization was undertaken arbitrarily or at the whims of the insured.”
indianexpress.com
Sources
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