DCDRC Orders Star Health to Pay ₹94,000 for Wrongful Hospitalisation Denial

• The DCDRC ordered Star Health to pay ₹94,000 as compensation for wrongful denial of a claim.
• The commission held that internal insurance desk reviews cannot override the firsthand clinical judgment of the treating physician.
• Star Health was directed to pay ₹58,729 with 9% annual interest from the date of filing until actual payment, in addition to ₹20,000 as compensation and ₹15,000 in litigation costs.

In its order, the DCDRC held that internal insurance desk reviews cannot override the firsthand clinical judgment of the treating physician.

The District Consumer Disputes Redressal Commission (DCDRC) has delivered a significant ruling that highlights the importance of insurers respecting treating doctors' decisions on hospitalisation. In a case involving Star Health and Allied Insurance Company Limited, the commission ordered the insurer to pay ₹94,000 as compensation for wrongful denial of a claim. The ruling underscores the potential consequences for insurers who fail to respect medical judgments.

Gurdeep Singh, a policyholder with Star Health's Family Health Optima plan, had filed a complaint against the insurer after it rejected his claim for ₹58,729. The rejection was based on the insurer's in-house medical team's assessment that the hospitalisation was medically unnecessary. However, the commission found that this assessment was not supported by evidence and that the treating doctor's decision to admit the patient was justified.

In its order, the DCDRC held that internal insurance desk reviews cannot override the firsthand clinical judgment of the treating physician. The commission noted that Star Health had not filed an affidavit from any member of its own medical team to support its claim, leaving its outpatient theory unbacked by evidence. As a result, the commission directed Star Health to pay ₹58,729 with 9% annual interest from the date of filing until actual payment, in addition to ₹20,000 as compensation and ₹15,000 in litigation costs.

This ruling has significant implications for insurers who may be tempted to override medical judgments. The commission's decision underscores the importance of respecting treating doctors' decisions on hospitalisation and highlights the potential financial consequences for insurers who fail to do so. Lawyers advising clients with similar cases may want to cite this precedent in arguing against insurer attempts to override medical judgments.

This ruling highlights the importance of insurers respecting treating doctors' decisions on hospitalisation, and underscores the potential for significant financial consequences when they fail to do so. Lawyers advising clients with similar cases may want to cite this precedent in arguing against insurer attempts to override medical judgments.

Source: Original reporting via a Himachal Pradesh consumer forum