24-hour hospitalisation clause for mediclaim to be interpreted harmoniously: Delhi consumer forum

PTI, Oct 9, 2024, 9:49 AM IST

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The central Delhi District Consumer Dispute Redressal Commission has directed an insurer to reimburse Rs 13,525 as medical expenses to a consumer, and said the clause of a minimum 24 hours’ hospitalisation for medical claims is to be “interpreted harmoniously” with facts of a case, including emergency treatment.

As the claim rejection caused mental agony and harassment to the consumer, the United India Insurance Company Ltd also had to pay Rs 5,000 compensation to him, the commission said.

The commission, comprising its president Inder Jeet Singh and member Rashmi Bansal, was hearing the complaint of Raja Harpal Singh, who said that his wife’s mediclaim was repudiated by United India Insurance on the grounds that hospitalisation in the case lasted less than 24 hours.

In a recent order, the commission said that according to the medical records, the complainant’s wife was admitted to hospital in an emergency, given medical treatment and then discharged on the doctor’s advice.

“The complainant has proved that his wife was admitted to the emergency ward on March 31, 2023, at 4:09 AM… The Opposite Party or OP (United India) in its repudiation letter also mentions the time and date of discharge as 6:06 PM on March 31, 2023. It is apparent that hospitalisation is about 13-14 hours, which is less than 24 hours,” it said.

The commission said that though clause 15 of the policy mentioned a minimum of 24 hours of hospitalisation to claim the insurance benefit, this clause was “general”, “based on traditional practice” and did not consider “subjective factors”.

It said, “There is diversification of the technology in all spheres of life. The medical sciences and its branches are advanced with technology. To put it in simple words, the advancement in technology means speed, accuracy in process and results as compared to traditional or manual tasks etc.” “Thus by the use of advanced equipment and tools in medical diagnosis, tests, reports, evaluations, treatment, management and post-care procedures, the hospitalisation timings of patients are reduced substantially,” the commission added.

The commission said the complainant’s wife required hospitalisation in the emergency ward and at the time of hospitalisation, the duration of treatment or stay in the hospital was not known.

“The reason for hospitalisation is a medical compulsion, one would always desire not to stay for a longer period in hospital. When there is quick treatment and recovery, then why the patient would stay in a hospital for over 24 hours at the perils of health risk and inflate the bills,” it asked.

The commission said the clause needed to be “construed harmoniously with other clauses of policy”, including that of emergency hospitalisation.

“The opposite party was not to reject the valid claim simply by the strict literal meaning of 24 hours of clause 15. It is to be interpreted harmoniously with the facts, features and circumstances of this case of treatment in an emergency …” it said.

The commission said the insurer could not reject the claim by ignoring the “material factors” of the case and without a “subjective assessment” of a patient’s needs.

“Further, it is not rewriting of the contract but to make its construction and interpretation harmoniously with the objective of insurance policy for the purposes of this case of complainant,” it said.

The commission concluded that the clause of 24-hour hospitalisation was not invoked properly and that the rejection of the claim was not justified.

So deficiency in service and the complainant suffering inconvenience and harassment for non-settlement of the claim was established, said the commission.

It directed the insurer to reimburse Rs 13,525 as medical expenses along with Rs 5,000 as compensation for causing mental agony and harassment to the complainant because of claim rejection and Rs 3,000 as litigation costs.