Denial of medical expenses for want of initial consultation report, MRI and Xray.
On 5.6.2019, the complainant met with an accident and admitted in the network hospital under the health insurance policy. Instead of cashless treatment, the complainant was directed to submit additional documents. However, the claim was repudiated for non-submission of initial consultation report, MRI and X-ray.
According to the complainant, the said documents were deemed unnecessary by the treating doctor and he had submitted all other documents.
HELD that the insistence on unnecessary documents by the opposite parties constitutes a clear deficiency in service. Insurance policy should be interpreted holistically to meet the reasonable expectations of all parties especially the insured. Coverage clauses must be read broadly with any ambiguities resolved in favour of the insured and exclusion clauses interpretation narrowly. This approach ensures that insurance serves its fundamental purpose of providing security and peace of mind during vulnerable times.
It is the duty of the doctor, not the patient, to determine the necessity of tests and reports like MRI and X-ray. In this case, the demand for documents deemed unnecessary by the doctor added undue stress and hardship to the complainant, highlighting a lack of compassion and fairness in handling the claim.
Judgment dated 24.6.2024 of the Consumer Disputes Redressal Forum, Ernakulam, in Complaint Case No.CC/20/153 of Saneesh M.S. Vs. Star Health & Allied Insurance
