Consumer court orders insurer to pay for inpatient diagnosis

AHMEDABAD: A policy holder is entitled to medical claims even if he or she is admitted to hospital for diagnosis and not treated for any ailment. A consumer court ordered an insurance company to pay the claim made by Pramukh Shah of Ambawadi, for tests he underwent while under monitoring by the doctor, who advised him to be hospitalized for the tests.
Shah, a senior citizen, was told by his consulting doctor have himself admitted to hospital in March 2017 for various medical tests because of his symptoms, loss of consciousness caused by a fall in blood pressure (syncope). Several tests were conducted on him and he was diagnosed as having coronary artery disease and recurrent syncope RHD. Shah claimed reimbursement of Rs 62,000, because he had a Rs 2 lakh insurance cover from the Oriental Insurance Co Ltd.
The insurer turned down Shah’s claim, saying it was not liable to pay because the hospitalization was primarily for diagnostic reasons, with no active treatment for his ailment. Citing the reports, the company said Shah was hospitalized primarily for diagnosis and it relied on a medical expert’s opinion that 2D Echo, EPS and RFA were conducted to determine why the patient fainted, but he was not treated for the illness.
Shah took the insurance company to the Ahmedabad Consumer Dispute Redressal Forum, which viewed the case differently. It concluded that the hospitalization was to evaluate the episode of syncope and to manage and control the ailment. The patient was kept under observation by a cardiologist for treatment of recurrent syncope and tachycardia (an abnormal rapid heart rate). This requires hospitalization and institutional care and it is not possible to undergo these tests as an outpatient. Hence, it can be termed active treatment.
The court discarded the opinion of the company’s expert, saying it was based only on case papers. He was not a treating doctor. It said that the insurer’s decision to reject the claim “suffers from serious infirmity and is without any justification and hence cannot be sustained”.
The court ordered the company to pay Shah Rs 60,628 with 8% interest and Rs 3,000 extra as compensation for the mental harassment he went through and legal expenditure.