Health insurance claim rejected over hospitalisation? Court rules in policyholder's favour

Delhi consumer commission ruled that health insurers cannot reject claims by declaring hospitalisation medically unnecessary without evidence.

Treating doctor's clinical judgment cannot be replaced by insurer's assessment, the commission held.

Oriental Insurance Co. Ltd. was directed to pay over ₹2.24 lakh to policyholder Shivani Tomar for claim rejection amounting to deficiency in service.

Tomar was admitted to Max Healthcare Hospital, Vaishali in November 2023 with chest heaviness, breathlessness, and other symptoms; insurer rejected claim citing normal vital parameters and diagnostic purpose.

The commission noted Oriental Insurance failed to appear or produce medical evidence to support its rejection.