Delhi Consumer Commission orders UIIC to reimburse medical expenses and compensation

The Central Delhi District Consumer Dispute Redressal Commission has ordered United India Insurance Company Ltd to reimburse ₹13,525 in medical expenses to a consumer. The ruling emphasizes that the clause requiring a minimum of 24 hours' hospitalization for medical claims should be interpreted in light of the specific circumstances of the case, particularly regarding emergency treatment.

In addition to the reimbursement, the commission also awarded ₹5,000 in compensation to the complainant for the mental agony and harassment caused by the claim's rejection. The decision was made by a commission panel led by President Inder Jeet Singh and Member Rashmi Bansal.

The case arose when Raja Harpal Singh filed a complaint after his wife’s mediclaim was denied by United India Insurance, citing that her hospitalization lasted less than the required 24 hours. The commission reviewed medical records indicating that the complainant's wife was admitted to the emergency ward on March 31, 2023, at 4:09 AM and discharged on the doctor’s advice at 6:06 PM the same day, amounting to approximately 13-14 hours of hospitalization.

The commission noted that while the insurance policy's clause 15 stipulated a minimum hospitalization period of 24 hours, this requirement was viewed as "general" and based on traditional practices that did not account for the subjective factors involved in medical emergencies.

Highlighting advancements in medical technology, the commission explained that modern diagnostics and treatments often allow for reduced hospitalization times. The ruling pointed out that when quick treatment and recovery are possible, there is no reason for a patient to remain in the hospital longer than necessary, especially if it poses health risks or leads to inflated medical bills.

The commission asserted that the 24-hour clause must be interpreted in conjunction with other policy provisions, including those related to emergency hospitalization. It criticized the insurer for rejecting the claim based solely on a literal interpretation of the clause without considering the unique factors of the case.

The commission concluded that the insurer failed to appropriately invoke the 24-hour hospitalization requirement, rendering the claim rejection unjustified. It confirmed that the complainant experienced a deficiency in service and significant inconvenience due to the non-settlement of the claim.

As a result, the commission directed United India Insurance to reimburse ₹13,525 for medical expenses, along with ₹5,000 for the mental distress caused by the claim denial and ₹3,000 to cover litigation costs.