“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,” the commission said on september 18. It added that an insured patient relies on the medical judgment of the attending doctor when decisions regarding hospitalisation have to be made.
2 emergency-room visits in 3 days
Brar left India for the US on January 1, 2023, to visit her daughter. On January 28, she developed a headache and experienced fluctuating blood pressure. Her daughter took her to the emergency room of a medical centre. Doctors conducted tests, including a complete blood count. The hospital’s after-visit summary recorded low sodium levels and elevated blood pressure. Brar was advised to restrict her fluid intake to one litre a day and have her sodium checked again after a week.
The hospital raised an invoice of $3,772 for the consultation and tests. On January 31, Brar returned to the emergency room after experiencing uneasiness and chest pain. The doctor prescribed tests, including a B-type natriuretic peptide test and a complete blood count. The hospital’s after-visit summary recorded chest pain and hypertension, with the diagnosis described as unspecified chest pain. The second invoice was for $9,335.50.
Insurer relied on policy exclusion
Brar returned to Delhi on March 30, 2023. After subsequent correspondence, the insurer rejected her claim through a letter dated March 18, 2024. Brar challenged the decision on June 7, 2024, but the claim was again denied by email on June 15, 2024.
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The insurer’s rejection relied on a policy exclusion relating to “Investigation & Evaluation”. The exclusion stated that expenses relating to admission, primarily for diagnostics and evaluation purposes, were not covered. Brar approached the consumer commission seeking settlement of the insurance claim and payment towards the hospital expenses. She also sought compensation for mental harassment and litigation costs.
The insurer did not appear before the commission despite notice, and was proceeded against ex parte (unilaterally) on December 20, 2024. Brar filed her evidence and supporting medical and insurance documents.
The commission examined the policy and medical records and noted that the policy provided overseas travel insurance coverage, including in the US and Canada. It also noted that Brar had gone to the nearest hospital after feeling unwell.
The commission did not accept the insurer’s reliance on the investigation-and-evaluation exclusion in the circumstances of the case. It said the decision on medical treatment rested with the treating physician rather than the insurance company. The commission also observed that a person travelling abroad would not ordinarily get herself admitted to a hospital merely for diagnostic purposes when such facilities were conveniently available in India.
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“Given these circumstances, it is implausible to suggest that hospitalization was undertaken arbitrarily or at the whims of the insured,” it said.
The consumer forum also referred to earlier consumer commission decisions involving similar exclusion clauses. Those decisions had considered circumstances in which diagnostic procedures formed part of treatment for an existing illness requiring hospitalisation.
The commission recorded that the total hospital bills amounted to $9,465.70. It held the insurer guilty of deficiency in service and unfair trade practice and directed it to pay Rs 9,06,625, calculated at an exchange rate of Rs 95.78 per US dollar as on the date of the order, with 7 per cent interest from the date of the order.
The insurer was also directed to pay Rs 25,000 as compensation for mental harassment and Rs 5,000 towards litigation costs. The commission gave the insurer 60 days to comply. If the order is not complied with within that period, the amount will carry interest at 8 per cent from the date of the order until realisation.
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Takeaway
A medical insurance company cannot automatically reject a claim just because tests were conducted during hospitalisation. If you fall ill abroad and seek emergency treatment, keep the hospital records, test reports, bills and discharge or after-visit summaries.
Consumers facing similar grievances may contact the consumer helpline in their respective states (Delhi: 011-23379146) or dial the National Consumer Helpline at 1915 for assistance.
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