With this observation, the Navsari Consumer Commission directed a private health insurance company to reimburse Rs 64,291 to a 34-year-old man who was hospitalised for acute pancreatitis back in January this year.
As per the case details, the patient had a mediclaim policy worth Rs 11.50 lakh. During his hospitalisation in January, 2025, the patient had been suffering from severe pain, weakness, and vomiting for three days. He was admitted to a private hospital in Navsari based on the doctor's advice and after being diagnosed with acute pancreatitis.
He received treatment at the hospital from January 11 to January 15 and was consequently discharged. For the treatment expenses, the patient filed a claim of Rs 64,921 with the insurance firm.
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As per the latest media report by the Times of India, the company rejected his claim on the grounds of 'discrepancy in medical documents.' Among other discrepancies in documents, the insurer cited issues such as the absence of a pathologoist's signature on lab reports and alleged discrepancies in medical records, including missing OPD consultation.
The firm also contested the lab report, citing that the total leucocyte count (TLC) was within limits when the patient was admitted. Besides, the insurer even claimed there couldn't have been vomiting during pancreatitis.
After taking note of the submissions, the consumer court scrutinised the evidence and arguments presented by both sides and observed that the insurer failed to substantiate its claims of fraud or discrepancies with concrete evidence.
It was observed by the Commission that in the digital age, the absence of a physical signature on medical reports should not be a basis for claim denial, especially when the authenticity of the reports could be verified through other means, including visiting the lab in person.
Accordingly, the Commission observed, "OPD consultation does not come into existence when the patient has emergency pain as he needs to be directly admitted to the hospital. The TLC report submitted by the insurance firm itself suggested that they were not within limits. The insurance firm's argument that vomiting takes place only when sodium and potassium are less is wrong, as this may also be triggered due to pancreatitis."
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