A Delhi court has ordered a private insurer to pay nearly Rs 9.07 lakh to a woman after it wrongly denied her emergency medical expenses incurred during a trip to the US, reinforcing that insurers cannot override medical judgment.
A Delhi consumer commission has ordered a private insurer to reimburse a woman nearly Rs 9.07 lakh after it refused to cover emergency treatment she received during a trip to the United States, reinforcing the view that insurers cannot substitute their judgement for that of treating doctors.
The District Consumer Disputes Redressal Commission, South II, Delhi, also directed the company to pay Rs 25,000 for mental harassment and Rs 5,000 in costs after finding that the claim had been wrongly denied. The panel, led by President Monika Aggarwal Srivastava and members Dr Rajender Dhar and Ritu Garodia, said the insurer had failed to justify its reliance on an exclusion for investigation and evaluation.
Arti Brar had travelled to the US on January 1, 2023, under an overseas travel policy that covered her until March 31, 2023. After developing headaches and fluctuating blood pressure on January 28, she was taken to an emergency department, where doctors carried out tests, including a complete blood count. Hospital records noted low sodium levels and high blood pressure, and she was told to limit fluid intake and recheck her sodium level a week later. Three days later, she returned to the emergency room with uneasiness and chest pain, prompting further tests and another invoice.
The insurer later rejected the claim, arguing that the hospital visits were covered by a policy exclusion for admissions mainly meant for diagnostics and evaluation. But the commission was unconvinced. It said the medical decision to hospitalise a patient belongs to the treating physician, not the insurer, and found it unlikely that a traveller would seek admission abroad merely to obtain tests that could have been done in India. The panel also pointed to earlier consumer rulings that had limited the reach of similar exclusion clauses where diagnostic procedures formed part of genuine treatment.
In a separate case reported by Livemint and The Economic Times, the Delhi consumer commission took a similar view, holding that an insurer could not reject a claim simply by declaring hospitalisation unnecessary when it had no medical evidence to support that conclusion. Those rulings underline a pattern in consumer forums: insurers may examine records closely, but they cannot overrule clinical judgement without a sound basis. At the same time, other Delhi decisions have shown that claims can still fail when records are found to be fabricated or inconsistent, leaving honest documentation central to the outcome.
The commission in Brar’s case recorded total hospital bills of $9,465.70 and converted the amount at an exchange rate of Rs 95.78 to the dollar, arriving at Rs 9,06,625. It held the insurer guilty of deficiency in service and unfair trade practice, and gave it 60 days to comply before a higher interest rate would apply.
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