A Delhi consumer commission has ordered a private health insurer to pay Rs 9.06 lakh to a woman whose medical claim for emergency treatment in the United States was rejected. The commission also awarded Rs 25,000 for mental harassment and Rs 5,000 towards litigation costs, according to The Indian Express news report.
The order, passed on September 18 by the District Consumer Disputes Redressal Commission, South II, Delhi, held that the insurer was guilty of deficiency in service and unfair trade practice for denying the claim on the ground that the hospital visits were primarily for “investigation and evaluation”.
2 emergency visits in three days
The complainant had travelled to the US on January 1, 2023 to visit her daughter. Her overseas travel insurance policy was valid until March 31, 2023. On January 28, she developed a headache and fluctuating blood pressure. Her daughter took her to the emergency room of a medical centre.
Doctors ran tests, including a complete blood count (CBC). The after-visit summary recorded low sodium levels and elevated blood pressure. She was advised to limit her fluid intake and recheck her sodium after a week. The hospital billed $3,772 for this visit.
Three days later, on January 31, the complainant returned to the emergency room with uneasiness and chest pain. Doctors again prescribed tests, including a B-type natriuretic peptide test and a complete blood count. The after-visit summary noted chest pain and hypertension, with the diagnosis listed as unspecified chest pain. The second bill was $9,335.50.
In total, the two emergency visits generated hospital bills of $13,107.50, though the commission’s final calculation for the payable amount was based on $9,465.70 after examining the documents on record.
Insurer cites ‘investigation and evaluation’ exclusion
The complainant returned to Delhi on March 30, 2023. After correspondence, the insurer rejected her claim through a letter dated March 18, 2024. She challenged the decision on June 7, 2024, but the claim was again denied by email on June 15, 2024.
The insurer’s rejection relied on a policy exclusion relating to “Investigation & Evaluation”. This clause stated that expenses relating to admission primarily for diagnostics and evaluation purposes were not covered.
She approached the consumer commission seeking settlement of the insurance claim, along with compensation for mental harassment and litigation costs, The Indian Express news report added. The insurer did not appear before the commission despite notice, and the case was heard ex parte on December 20, 2024.
Commission: Treatment choice lies with the doctor
The commission examined the policy wording, medical records and after-visit summaries. It noted that the policy provided overseas travel insurance coverage, including in the US and Canada, and that the complainant had gone to the nearest hospital after feeling unwell.
“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.
It added that an insured patient relies on the medical judgment of the attending doctor when decisions regarding hospitalisation have to be made. The commission also observed that a person travelling abroad would not normally seek hospital admission merely for diagnostic purposes when such facilities were easily available in India.
“Given these circumstances, it is implausible to suggest that hospitalisation was undertaken arbitrarily or at the whims of the insured,” the order said.
The forum referred to earlier consumer commission decisions involving similar exclusion clauses, noting that diagnostic procedures often form part of treatment for an existing illness requiring hospitalisation.
Final order and interest
The commission recorded that the total hospital bills amounted to $9,465.70. It directed the insurer 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% interest from the date of the order.
In addition, the insurer was ordered 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 amount is not paid within that period, it will carry interest at 8 per cent from the date of the order until realisation.
The case makes it clear that a health insurance company cannot reject a claim simply because medical tests were carried out during hospitalisation, particularly when emergency treatment is needed abroad. If you fall ill while travelling overseas, keep all hospital records, after-visit summaries, test reports, prescriptions, original bills, payment receipts and discharge summaries safely.
These documents can help support your insurance claim. If you face a similar problem, you can contact your state consumer helpline. In Delhi, you can call 011-23379146, or you can reach the National Consumer Helpline at 1915 for assistance.