A Himachal Pradesh consumer commission has mandated Star Health and Allied Insurance to reimburse a family over wrongful rejection of a child’s hospitalisation claim, emphasising the importance of medical opinion in insurance disputes.
A Himachal Pradesh consumer commission has said Star Health and Allied Insurance Company acted unlawfully when it rejected a child’s hospitalisation claim on the grounds that the admission was not medically necessary, ordering the insurer to pay the family’s medical bill and additional compensation.
The Kangra District Consumer Disputes Redressal Commission, headed by Hemanshu Mishra with members Arti Sood and Narayan Thakur, heard the complaint filed by Gurdeep Singh against Star Health and Allied Insurance Company. According to the order reported by The Indian Express, the commission said the insurer’s stance was “completely wrong, illegal” because the decision to admit a patient must rest with the treating doctor, not an in-house medical team.
Singh’s son fell ill in August 2023 with a high fever and severe throat pain. He was first admitted to Zonal Hospital in Dharamshala, then shifted on the advice of doctors to City Hospital in Matour, Kangra, where he remained in care until August 17, 2023. The child was diagnosed with acute fever with thrombocytopenia, a low platelet count, and transaminitis, meaning elevated liver enzymes. Singh had bought a Family Health Optima policy in 2021 and renewed it repeatedly, including in August 2023.
The family said the treatment cost Rs 58,729 and that the insurer was notified during the hospital stay. Star Health rejected the claim in September 2023, arguing that its medical team believed the child could have been treated as an outpatient. The company also relied on a policy exclusion covering admissions that were not medically necessary. But the commission found that the child’s earlier admission, the continuing symptoms and the treating doctor’s certificate all supported the need for hospital care. LiveMint and The Economic Times have reported similar consumer rulings in which commissions held that insurers could not overrule a doctor’s clinical judgement without proper evidence.
The commission also rejected the insurer’s attempt to rely on an unsigned bill assessment sheet showing a lower amount, noting that Star Health had not supported its position with an affidavit from any member of its medical team. It ordered the company to reimburse the full Rs 58,729 with 9% annual interest from the date the complaint was filed until payment, along with Rs 20,000 in compensation and Rs 15,000 towards litigation costs.
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