24 Hrs Hospitalisation Avoided Due To Technological Advancement, Kerala Consumer Forum Directs Insurer To Reimburse Policy Holder Discharged Same Day

A Consumer Commission in Kerala has ordered an insurance company to reimburse the medical expenses borne by a policy holder for treatment of his mother (included in the policy) even though she was not hospitalised for 24 hours, upon noting that as per IRDAI guidelines the treatment given to her should not be excluded in health insurance policies.

The Bench comprising President D.B. Binu and Members Ramachandran V and Sreevidhia T.N also observed that the procedure should be viewed as "day care treatment" which includes medical procedure that would require hospitalization of more than 24 hours but was undertaken in less than 24 hours due to technological advancement.

Complainant's mother was diagnosed Myopic Choroidal Neovascular Membrane in her left eye and sought reimbursement of Rs. 27,720 expense incurred as an "inpatient for a day care treatment".

The Company argued that the treatment for this condition involves Accentrix eye injection, which is an "outpatient procedure".

Disagreeing, the Commission pointed that under guidelines issued by Insurance Regulatory and Development Authority of India, "Intra vitreal injections" should not be excluded in health insurance policies.

"The Complainant contends that the rejection is based on false grounds and constitutes unfair trade practice. The policy terms and guidelines do not exclude the procedure, and the patient was discharged on the same day due to advanced technology and infrastructure...The Opposite Party's rejection of the claim based on this procedure contradicts the IRDAI guidelines," the Commission remarked.

It also noted that the insurer was taking an inconsistent stand on the issue inasmuch as a similar procedure undergone later that year was allowed by it without objection.

"This inconsistency in the Opposite Party's actions suggests an unfair trade practice," Commission said while ordering the insurer to reimburse the hospitalization expenses to the Complainant and pay Rs 20,000/- as compensation for the deficiency of service, mental agony, and physical hardships. It also awarded Rs. 10, 000/- litigation cost.