Modern technology negated 24 hour hospitals stay, Insurance companies cannot deny claims : Consumer Court

Vadodara: Upholding the order, a Consumer Court in Vadodara has ruled that the 24-hour hospitalization of the patient as per the clause for Mediclaim, is not necessary because the introduction of new technologies has replaced the necessity to stay in hospital. Furthermore, the insurance companies cannot deny claims.

The ruling came out to be in favor of Arvind Suthar and Hansa Suthar, who underwent treatment for retinal vascular occlusion in 2016.

New India Assurance Company and the Third-Party Administrator (TPA) rejected their claim for over Rs 43,000 for their treatment.

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The insurer told TOI "the treatment given to the patients is usually done on an out-patient department (OPD) basis and does not require hospitalization. Also, the treatment taken doesn't fall under the definition of hospitalization nor is it listed as a daycare procedure for the purpose of the policy. Even if injected during hospitalization for other conditions or during other accepted daycare procedures, it shall continue to be non-payable."

Similarly, the insurer also defined hospitalization as admission for a minimum of 24 consecutive hours of in-patient care within a hospital, except for specific procedures/treatments, which may require less than 24 hours of hospitalization due to advancement in technology or any surgery/procedure agreed to by a TPA/company requiring less than 24 hours of hospitalization.

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The New India Assurance Co. Ltd., based in Mumbai, Maharashtra is a nationalized general insurance company. It is under the ownership of the Ministry of Finance, Government of India. It is the largest nationalized general insurance company of India on the basis of gross premium collection inclusive of foreign operations. It was founded by Sir Dorabji Tata in 1919 and was nationalized in 1973.

Previously, it was a subsidiary of the General Insurance Corporation of India (GIC). But when GIC became a re-insurance company following the passage of the IRDA Act 1999, its four primary insurance subsidiaries New India Assurance, United India Insurance, Oriental Insurance and National Insurance became autonomous.