Insurer Told To Pay Full Claim After Denying Pregnant Woman's Hospital Bill

A local consumer court has ordered a health insurance firm to reimburse the medical expenses of a pregnant woman, along with interest and compensation, after rejecting her hospitalisation claim without solid medical grounds, according to a recent news report by The Hindu.

'Admission Not Justified,' Said The Insurer

The case dates back to October 2023, when the woman, who was pregnant at the time, developed fever, body aches, and throat pain. On the advice of her doctor, she was admitted to Father Muller Hospital in Mangaluru for five days. The total bill came to Rs 45,704.

She had an active health policy with Care Health Insurance, renewed regularly through her Union Bank of India account. Despite submitting the necessary documents, her request for cashless hospitalisation was denied. The insurer followed up with two rejection letters, saying the admission was "not justified" and labelling the treatment as one meant "primarily for investigation," which it claimed was excluded from coverage.

Not convinced, the woman took the case to the consumer forum. 

Consumer Forum Finds No Valid Basis For Rejection 

The district consumer reviewed the case. The ruling was made in favour of the woman. The bench noted that the health insurance company failed to provide the required medical proof to support their claim that hospitalisation was not required. They didn't submit supporting records, nor did they consult or question the treating doctor.

The commission found that the rejection had no medical backing and went against the spirit of the policy agreement. They observed that denying a claim in a case where a doctor advised admission—especially during pregnancy—amounted to a deficiency in service.

Interest, Compensation, And Legal Costs Awarded

In its order dated July 18, the commission directed the insurer to pay the full claim amount of Rs 45,704 with six per cent annual interest from the date of rejection until the payment is made. It also asked the company to compensate the complainant with Rs 10,000 for mental distress and pay an additional Rs 5,000 to cover her legal expenses.

The ruling sends a strong message to insurers: claims can't be rejected without solid evidence. For consumers, it means they do not have to accept arbitrary claim rejections and have the right to question unfair denials and seek redress. Medical advice from a qualified doctor carries weight, and insurance companies must honour valid hospitalisation claims.