'Only doctor can decide about hospitalisation': Court orders Star Health to pay compensation for rejecting claim

economictimes.indiatimes.com:

In a significant ruling in favor of Amitkumar Goyal, a resident of Vyara in Tapi district, the commission overturned Star Health and Allied Insurance Co's rejection of his mediclaim of Rs 86,250 for a hospital bill, citing the 'admission not required' clause. According to the case details, Goyal had purchased a mediclaim policy of Rs 10 lakh from the insurance company for the period from April 30, 2020, to April 29, 2021. On November 18, 2020, he was admitted to a private hospital in Surat, where he was diagnosed with viral pneumonia and Covid-19.

After receiving treatment, he was discharged on November 25. However, on February 22, 2021, the company rejected his claim, prompting Goyal to approach the consumer commission, seeking compensation for mental harassment and the hospital expenses. During the hearing, the insurance company argued that hospitalization was unnecessary as Goyal's illness was not severe.

Conversely, the complainant presented his Covid-19 report and CT scan, which showed 20 per cent to 25 per cent infection in his lungs. The Commission firmly asserted that the decision of whether a patient requires hospitalization is best left to the expertise of doctors. It further criticized the insurance firm for disregarding the CT scan report, which indicated Covid-19 infection.