Insurance claim cannot be rejected just because doctor is a relative, rules Consumer court, calls 'inflated bills' assumption wrong
Surat: In a recent judgment, the Surat Consumer Disputes Redressal Commission has ruled that a medical insurance claim cannot be rejected simply on the ground that the doctor is a relative of the patient.
The consumer court observed that it cannot be assumed by the insurance company that a patient will receive an inflated bill simply because the treating doctor is a relative. Further, it noted that for this reason, a patient cannot be prevented from seeking treatment from a family member, which is a fundamental right under the Constitution.
These observations were made by the consumer court while considering the complaint filed after an insurance company refused to pay a hospital bill of Rs 1.91 lakh for the treatment of a 57-year-old woman's husband.
As per the latest media report by the Times of India, the complainant had a mediclaim policy of Rs 8 lakh, which was valid from January 17, 2024. During this period, the complainant's husband was hospitalised on April 12 with a neoplastic lesion (tumour) on the scalp and was discharged the next day.
However, citing exclusion clause 50, under which claims are barred if the patient is treated by a relative of the insured, the insurer rejected the claim. Thereafter, the woman approached the Surat District Consumer Court on July 11, 2024.
After taking note of the arguments by both sides, the District Commission ordered the insurance company to pay the full claim of Rs 1.91 lakh, along with Rs 12,000 for mental harassment and Rs 8,000 as application costs.
While passing the order, the consumer court also criticised the assumption by the insurer that the relatives would inflate the bills. The Commission observed in the order, "Parents, children, and other family members have the right to get treatment from a doctor of their choice. It is unfair to presume that a doctor will misuse their position or raise charges simply because the patient is a relative."
Further, the Commission added that even the family members who do not share warm relations often prefer treatment from a known doctor, and in many cases, parents and their doctor-children live separately and have independent finances.
Apart from this, the Consumer Court also clarified that under the Fundamental Right to Freedom, every citizen has the right to choose their doctor and restrictions cannot be imposed by an insurance company to violate this constitutional right.
Also Read: Mediclaim cannot be rejected citing existing illness: SC
