Insurance company ordered to pay for emergency care at non-approved hospital
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In Ernakulam, India, the District Consumer Dispute Redressal Commission ordered an insurance company to pay Rs 1.73 lakh (approximately $2,080 USD) to a woman whose medical claim was initially rejected.
The woman, a beneficiary of the Medical Insurance Scheme for State Employees and Pensioners (MEDISEP), received emergency treatment at a hospital not approved by the insurance scheme.
The commission found the rejection unjustified, noting the woman was taken to the nearest hospital by family members experiencing shortness of breath, fatigue, and discomfort. The commission argued it was unreasonable to expect the woman, or her family, to verify hospital empanelment during an emergency. They also stated the insurance company did not prove the woman was capable of directing her family to a specific hospital or that those present had the medical expertise to diagnose her condition.
The authorities and insurance provider maintained that the MEDISEP scheme only covered cashless treatment at empanelled hospitals, with limited exceptions for specific emergencies. The commission ruled the claim rejection was based on flimsy grounds and ordered the insurance company to cover the Rs 1.18 lakh in hospital expenses. They also added Rs 50,000 to compensate for the woman’s distress and Rs 5,000 for litigation costs, emphasizing the need for insurance companies to properly process claims and address consumer concerns.
