A District Consumer Dispute Redressal Commission (DCDRC) in Delhi recently ordered United India Insurance Company Limited to pay ₹5,000 as compensation for mental agony and harassment suffered by a man (complainant) due to denial of his medical insurance claim on the ground that the period of hospitalisation was less than 24 hours.
The Court also directed the insurance company to reimburse ₹13,525, the amount which was claimed by the complainant, one Harpal Singh, as insurance.
Besides, the company was directed to pay ₹3,000 as litigation costs.
A Coram of DCDRC President Inder Jit Singh and member Rashmi Bansal said that due to technological advancements in medical science, hospitalization timings of patients have substantially reduced.
Hence, the 'minimum 24-hour hospitalization' clause in the insurance policy should not be considered strictly but should be interpreted harmoniously with the facts and circumstances of each case of treatment.
"The opposite party could not reject the claim by ignoring the material factors of ailment, emergent need, treatment, care and recovery, since the term of 24 hour is general standard for all general geographical situation of the region/country without subjective assessment of need in case," the forum said in its September 7 order.
It noted that at the time of the patient's admission, the estimated hospitalization period may have been longer than the actual time required for the patient's treatment and recovery.
Thus, it held that the 24-hour hospitalization policy for medical insurance claims is general and based on traditional practice without considering subjective factors like technological advancements in medical science and quick recovery in certain cases.
"Since there were availability of all need requirements, doctors, improved conditions, attentions and because of their cumulative efforts, discussed in this paragraphs the recovery expedited and reduced stay hours, otherwise it may have longer stay," it noted.
Singh moved the DCDRC alleging that despite having a valid insurance policy, his claim was unjustifiably denied by United India Insurance in respect of the hospitalization and treatment of his wife who was rushed to BLK Max Hospital after suffering an acute stomach pain.
Singh had claimed an insurance benefit of ₹13,525 from the insurance company and had submitted all relevant documents regarding the same.
However, the claim was denied by the insurer based on the insurance policy's terms, specifically 'clause 15', which requires hospitalization for at least 24 consecutive hours.
The insurance company argued that since the patient was hospitalized for less than 24-hours, the claim was rightly rejected.
Singh submitted that determination of the length of hospitalization is not within a patient’s control as discharge decisions are taken by doctors. He further submitted various judgments wherein it was held that a 24-hour hospitalization is not mandatory for release of insurance claims.
After considering the submissions, DCDRC allowed the complaint and ordered the insurance company to reimburse the complainant and also pay him compensation for denying the claim.
Singh appeared in person while advocate Sidharth Handa represented United India Insurance Company.
[Read Order]