24-hr hospitalization condition anti-consumer – Forum

Nashik: The consumer forum here has termed “vexatious” the clause of medical insurance companies mandating the minimum 24-hour hospitalization for raising claims for treatment received during the period.

‘We are of firm belief that the minimum 24-hour-admission compulsory clause for the patients to be able to receive any claim from medical insurance companies is vexatious, anti-consumer and cheating on part of the ones who pay for the health insurance. If the patient has not been hospitalised for 24 hours, even in that case treatment has been provided to patient at some cost. It is the insurance company’s responsibility to settle the claims,” a three-member bench of the forum said while deciding on a complaint registered by Vasant Chintaman Kshirsagar, a resident of Sharayu Nagari near Indiranagar.

The complainant was that the beneficiary of the group insurance policy cover given by New India Assurance Company Limited up to the benefit of Rs 4,00,000 when he was working with the firm. The complainant underwent a surgery for heart ailment on November 4, 2014 when the policy was active.

On December 11, 2014, since he had pains in brain, left hand and left shoulder, Kshirsagar was admitted to the same hospital where he underwent the surgery before. The treatment cost him Rs 13,576, without being admitted for over 24 hours. Kshirsagar had sought reimbursement through the insurance claim as policy was live till March 2015.

The insurance company, however, denied the claim since the hospitalistaion was not for more than the period of 24 hours. “I was admitted to the hospital and was administered treatment which cost me. I was released within 24 hours of time. But when I pressed for my claim, the company refused to give me anything in return. Being a pensioner, each penny counts for me,” Kshirsagar said in the complaint registered with the consumer forum on September 1, 2015.

The insurance company in its reply to the consumer forum has said there was no deficiency in services provided by the company, especially in the event that there was no hospitalization at least for 24 hours and as a result the claim had been rejected. “As per the exclusion clause of claims, the claim has been rejected and it is in public domain as well as the customer is also aware of the same,” the company said.

The three members of the forum found it injustice on the part of the consumers that they were rejected claim for the 24-hour norm despite the patient being admitted overnight. Kshirsagar was admitted to the hospital on December 11 and released on December 12, but within 24 hours.

The forum has asked the insurance company to settle the claim along with a 10% interest rate from 10 February 2015 and pay Rs 5,000 as compensation for mental and physical harassment and Rs 3,000 as compensation for the expenses incurred.