Ms. SHIVANI TOMER v. THE ORIENTAL INSURANCE CO.

The case of the complainant is that she is one of the insured beneficiaries under Health Insurance Policy No. 252100/48/2024/2474 issued by Opposite Party No.1. According to the complainant, the policy has been continuing since 22.11.2010 and the premiums under the policy have been regularly paid from time to time. The complainant submits that she was entitled to avail the benefits available under the said policy, including cashless hospitalization and reimbursement of admissible medical expenses.

It is the case of the complainant that on 25.11.2023 she was admitted in Opposite Party No.2 hospital after suffering from severe acute gastric symptoms, severe throbbing headache, hypothyroidism, low blood pressure, severe abdominal pain, palpitations, nausea and constipation. It is stated that immediately upon hospitalization, intimation was furnished to Opposite Party No.1 for availing cashless treatment under the policy.

The complainant alleges that despite a valid insurance policy being in force, Opposite Party No.1 failed to grant cashless authorization. Consequently, the complainant was constrained to incur the entire hospitalization expenditure herself and paid an amount of ₹1,54,144/- towards her treatment. It is further alleged that thereafter the complainant submitted a claim for reimbursement of the aforesaid medical expenses. However, claim bearing No. 6431435 was rejected by Opposite Party No.1. As per the rejection letter, the claim was declined on the ground that all investigation reports and vital parameters of the patient were normal; that no active line of treatment had been administered; and that the patient had undergone diagnostic tests and hospitalization only for observation and evaluation purposes and, therefore, the hospitalization was not justified under the policy terms. The complainant submits that the aforesaid rejection was arbitrary, illegal and contrary to the terms and conditions of the policy. It is her case that she remained hospitalized for treatment of her ailments and underwent various investigations and medical management during the course of hospitalization.

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The complainant further states that despite repeated requests and follow- ups, Opposite Party No.1 failed to release the claim amount. Thereafter, a legal notice dated 23.02.2024 was sent to the Opposite Parties, but the grievance remained unresolved.

Aggrieved by denial of cashless treatment and rejection of her reimbursement claim, the complainant filed the present complaint seeking reimbursement of the medical expenses incurred by her along with compensation and litigation costs.

Proceedings before the Commission

Notice of the complaint was issued to the Opposite Parties. Despite service, the Opposite Parties failed to appear and contest the proceedings. Opposite Party No.1 failed to file its written version within the prescribed period and, vide order dated 20.12.2024, its right to file written statement was closed.

The complainant filed her evidence by way of affidavit and relied upon the Admission Certificate (Ex. CW-1/A), Bill Summary (Ex. CW-1/B), Discharge Summary (Ex. CW-1/C), Medical Reports (Ex. CW-1/D Colly.), Discharge Slip (Ex. CW-1/E), Insurance Policy along with denial/rejection letter (Ex. CW-1/F) and Photograph and Aadhaar Card (Ex. CW-1/G). Since no evidence was adduced by the Opposite Parties, the evidence led by the complainant remained unrebutted and unchallenged.

Findings by the Commission

This Commission has carefully considered the pleadings, affidavit evidence and documents placed on record.

The insurance policy bearing No. 252100/48/2024/2474 placed on record reflects the complainant as one of the insured beneficiaries. The policy further records continuity from 22.11.2010. Thus, the existence of a valid and subsisting insurance policy at the relevant time stands established.

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The complainant has placed on record the Bill Summary showing medical expenditure of ₹1,54,144/-. The said document has remained unrebutted. The discharge summary and medical records reveal that the complainant was admitted with complaints of palpitation, chest heaviness/discomfort, breathlessness, and constipation. The medical record further shows that during hospitalization the complainant underwent various investigations including biopsy, endoscopy, ultrasound, MRI and other diagnostic procedures. The treatment records also indicate administration of IV fluids, IV antibiotics and other supportive treatment. Upon evaluation, the complainant was diagnosed with severe acute gastritis, severe throbbing headache, hypothyroidism and ovarian cyst.

The nature of investigations conducted and the treatment administered during hospitalization demonstrate that the complainant was under active medical evaluation and treatment. The investigations reflected in the record, particularly biopsy, endoscopy, MRI and ultrasound, coupled with the symptoms recorded at admission, cannot be equated with routine outpatient consultation.

The rejection letter issued by Opposite Party No.1 shows that the claim was declined on the ground that all investigation reports and vital parameters of the patient were normal; that no active line of treatment had been given; and that the patient underwent hospitalization only for observation and evaluation purposes. Reliance was also placed upon Clause 5.2 of the policy excluding expenses relating to admission primarily for diagnostic and evaluation purposes. This Commission is unable to accept the aforesaid stand. The word "primarily" occurring in the exclusion clause is of significance and denotes that the dominant purpose of hospitalization must be diagnostic evaluation alone. The material placed on record demonstrates that the complainant was admitted with specific medical complaints requiring medical attention and the conducted tests are the based on those diagnosis. The

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complainant underwent multiple investigations as well as treatment during hospitalization. Therefore, the hospitalization cannot be said to have been undertaken merely for diagnostic and evaluation purposes. The discharge summary itself records the diagnosis arrived at and the treatment administered. In the absence of any evidence from the Opposite Parties to establish that hospitalization was unnecessary or that the admission was solely for observation and evaluation, the rejection of the claim cannot be sustained.

It is well settled that the necessity of hospitalization is a matter best assessed by the treating doctors. An insurance company cannot substitute its own assessment in place of the clinical judgment of medical professionals, particularly when no contrary medical evidence has been produced. Insurer cannot override a doctor's clinical judgment to reject claim. Medical necessity is based on a doctor's assessment, not the insurer's interpretation of symptom severity. Even if symptoms appear mild, hospitalisation is valid if tests or vitals show risk and the doctor justifies admission.

The complainant was covered under a valid policy and was entitled to avail the benefits flowing therefrom. Denial of cashless authorization during hospitalization and subsequent rejection of reimbursement have deprived the complainant of the benefits under the policy and compelled her to bear the entire treatment expenses.

Accordingly, this Commission holds that the Opposite Party was deficient in service in denying cashless treatment and in rejecting the reimbursement claim of the complainant.

Relief

In view of the foregoing discussion, the complaint is allowed. The Opposite Party no. 1 is directed to pay to the complainant the claim amount of ₹1,54,144/- (Rupees One Lakh Fifty-Four Thousand One Hundred

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Forty-Four Only) along with interest @ 6% per annum from 29.12.2023, i.e., the date of rejection of the claim, till realization. The Opposite Party no 1 is further directed to pay a sum of ₹50,000/- towards compensation for mental agony, harassment and financial hardship suffered by the complainant on account of denial of cashless treatment and rejection of the insurance claim.

The Opposite Party no. 1 shall also pay litigation costs quantified at ₹20,000/-.

The aforesaid amounts shall be paid within 30 days from the date of receipt of a copy of this order.

In the event of default, the Opposite Party no 1 shall be liable to pay interest @ 9% per annum on the entire awarded amount i.e. ₹1,54,144/- +₹50,000/- +₹20,000/-.= ₹ 2,24,144/- from the date of default till realization. The complaint stands disposed of accordingly.

Copy of this order be supplied to the parties free of cost as per the provisions of the Consumer Protection Act, 2019. Thereafter, the file be consigned to the Record Room.

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Divya Jyoti Jaipuriar, President

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Dr. Rashmi Bansal, Member

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