Not upto Insurer to decide treatment

Docs decide method & line of treatment, not insurance firms: Court

Jaideep.Deogharia@timesofindia.com writes in the Times of India today:

Ghaziabad : Decisions on line and method of treatment are not the insurance company’s to make but the medical fraternity’s, the district consumer commission has ruled in a case related to rejection of a claim to a Covid patient.

The order came while the panel was hearing a complaint against Star Health and Allied Insurance, which had denied a Covid-related claim on the grounds that the patient was asymptomatic and should have been treated in home isolation.

Star Health Insurance is well known

The commission directed the insurer to settle the claim of around Rs 50,000 with a 6% annual interest and pay an additional Rs 2,000 towards litigation costs within 30 days. The case was filed by Dadri resident Nitu Nagar, who approached the district consumer disputes redressal commission (DCDRC) on Sept 1, 2022, seeking relief after her medical claim was rejected.

When Insurance companies refuse payment

Nagar told the commission that her husband, Ajay Nagar, had been a policyholder with Star Health since 2018. The claim was raised in Jan 2022, during the fourth year of coverage, when she was admitted to hospital for high fever and breathing difficulty.

Before admission, her family informed the insurer and were told that the cashless claim would be approved within days, but insurer later refused to clear the bill of Rs 49,423. When the family’s reimbursement claim was not honoured, Nagar sent a legal notice to the insurer.

During proceedings, Star Health claimed that Nagar’s condition did not necessitate hospitalisation and could be managed at home as per govt guidelines.

The commission, however, held that an insurer cannot override a doctor’s decision.