5 min readNew DelhiAug 11, 2026 06:00 PM IST
First published on: Aug 11, 2026 at 06:00 PM IST
Holding the insurer’s rejection of a child’s hospitalisation claim to be “completely wrong, illegal” and a deficiency in service, a Himachal Pradesh consumer body has ordered an insurer to reimburse Rs 58,729 to a complainant and pay Rs 35,000 in compensation and litigation costs. The insurer had rejected the claim saying that the hospitalisation was not medically necessary.
Kangra District Consumer Disputes Redressal Commission president Hemanshu Mishra and members Arti Sood and Narayan Thakur were hearing a complaint filed by Gurdeep Singh against Star Health and Allied Insurance Company Limited.
“It is not for the insurance company’s medical team to decide who should be treated as an indoor patient or who should be treated at home for any illness. It is the treating doctor who must make that decision, and once he has issued a certificate stating that treatment was required in the hospital, the repudiation of the claim is completely wrong, illegal, and amounts to a deficiency in service,” the court said on July 29.
The dispute arose after Singh’s son fell seriously ill in August 2023 with high fever and severe throat pain. He was first admitted to Zonal Hospital, Dharamshala. When there was no improvement, he was discharged on request on August 12 and admitted the same day to City Hospital, Matour, Kangra, on the advice of treating doctors. He remained hospitalised until August 17, 2023.
Child’s hospitalisation, insurance dispute
The complainant bought a Family Health Optima policy in 2021, covering his wife and two sons, and renewed it on August 11, 2022, August 11, 2023 and August 11, 2024. On August 10, 2023, his son Agam developed high fever and severe throat pain and was admitted to Zonal Hospital, Dharamshala.
He was shifted to City Hospital on August 12 and diagnosed with acute fever with thrombocytopenia (low blood platelet count) and transaminitis (high level of liver enzymes). He remained hospitalised until August 17 and received intravenous fluids and antibiotics.
The treatment cost Rs 58,729. Singh informed the insurer on August 15, 2023, but Star Health rejected the claim on September 20, 2023.
‘Hospital admission unnecessary’
Star Health admitted before the commission that the health insurance policy was in force and had been renewed, but denied any deficiency in service. The insurer said its in-house medical team had scrutinised the medical records and concluded that “the insured patient could have been treated as an outpatient” and hospitalisation “was not warranted” for the diagnosis. It said the patient’s vital parameters and investigation reports were within normal limits.
The company relied on Code Excl 36 of the policy, which excludes hospitalisation that is not medically necessary or does not warrant hospitalisation. On this basis, Star Health maintained that the claim had been correctly rejected.
Commission backs doctor’s assessment
The commission examined the medical records and found that the circumstances supported the decision to hospitalise the child. It noted that Agam had already been admitted to Zonal Hospital before being shifted to City Hospital and that his medical records documented continuing symptoms.
It also noted that Star Health had not attached an affidavit from any member of its medical team to support its conclusion that hospitalisation was unnecessary. The forum held that the decision on whether a patient should be treated as an indoor patient or at home was for the treating doctor to make. Since the treating doctor had certified that hospital treatment was required, the commission found the insurer’s rejection of the claim to be wrong, illegal and a deficiency in service.
The commission also examined the evidence regarding the medical expenses. Singh produced bills totalling Rs 58,729. Star Health relied on an unsigned bill assessment sheet showing Rs 33,727, but the commission noted that no affidavit had been filed in support of that document. It, hence, accepted the complainant’s evidence regarding the total expenditure.
Allowing the complaint, the commission directed the insurer to pay Singh Rs 58,729 with 9 per cent annual interest from the date of filing until realisation. It also awarded Rs 20,000 compensation and Rs 15,000 litigation costs.
Takeaway
Insurers cannot simply override a treating doctor’s decision to hospitalise a patient by relying on an internal medical assessment. Policyholders should preserve the treating doctor’s certificates, hospital records, bills and claim correspondence when challenging a mediclaim rejection. The commission’s ruling, however, is specific to the facts and evidence before it.
Aggrieved consumers may contact the consumer helpline in their respective states (Himachal Pradesh: 1800-180-8087) or call the National Consumer Helpline at 1915 for assistance.
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A total 60 infant deaths were reported at hospital in August. 
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