‘Doctor, not insurance firm, decides patient’s case’
CHENNAI: It is the doctor who can decide if a patient requires admission, not the insurance company, ruled a consumer forum recently.The District Consumer Redressal Forum, Chennai (North), presided over by K Jayabalan, directed Apollo Munich Health Insurance to pay Rs 20,000 as compensation to a health insurance policy holder for rejecting his claims.
Sandeep Kumar Ranka, the complainant from Sowcarpet was issued a policy named Optima Restore Floater (Two Years) by Apollo Munich on April 3, 2015, for a sum of Rs 5 lakh. On July 9, 2015, Ranka suffered from fever, headache, vomiting and giddiness and underwent a preliminary treatment for next two days. When his condition deteriorated, following the advice of doctors, Ranka’s father admitted him in the Apollo Hospitals in Mint on August 11, 2015.
Ranka sought cashless hospitalisation, which was apparently not honoured. After his discharge, the complainant made claim for his medical expenses and it was allegedly rejected by them stating that the treatment was not related to illness and only for diagnosis. “The best judge to decide whether the patient was to take treatment as an inpatient or not is only the doctor,” the forum observed on February 14. “The opposite parties/insurance company’s terms and conditions that the investigation and evaluation purpose are not required as an inpatient treatment are not acceptable. The complainant was admitted as an inpatient with high fever. Therefore, the rejection of the claim is not accepted.”
The insurance company contended that the documents submitted by Ranka clearly showed no significant findings in the physical examination. They claimed that his admission was not justified and that the claim made by him for diagnostic purpose was not sustainable.