Insurer rejects child’s hospitalisation claim as ‘unnecessary’, father wins Rs 94,000 payout

In a case involving a child's hospitalization claim, a Himachal Pradesh consumer body has ordered an insurer to pay Rs 94,000 to the complainant. Gurdeep Singh filed a complaint against Star Health and Allied Insurance Company Limited regarding his son Agam's hospitalization expenses. The insurer had initially rejected the claim, stating that the hospitalization was not medically necessary.

However, the Kangra District Consumer Disputes Redressal Commission disagreed with the insurer's decision, ruling that the insurer's medical team should not make such determinations. Instead, the treating doctor holds the authority to decide whether a patient should be treated as an indoor patient or at home. The commission found that the treating doctor had certified the need for hospitalization, making the insurer's rejection unlawful and a deficiency in service.