Noida: The District Consumer Disputes Redressal Commission (DCDRC) has directed Gurgaon-based Care Health Insurance Company Limited and the Noida branch of Union Bank of India to reimburse Rs 1,53,709 towards a mediclaim, along with 6% annual interest from the date of filing of the complaint and Rs 5,000 as litigation cost. The amount is to be paid within 30 days of the order. Commission president Anil Kumar Pundir and member Anju Sharma, in an order dated March 5, ruled in favour of complainant Rajesh Kumar Sharma, a resident of Sahberi. It observed the decision to hospitalise a patient rests with the treating doctor. “Only a doctor can decide whether a patient should be treated in hospital, based on the patient’s condition. Insurance company cannot make any decision in this regard, and rejecting the complainant’s claim solely on this basis is unfair and constitutes deficiency in service,” the commission said. Sharma had filed the complaint on July 12, 2023, stating that he had purchased a mediclaim policy from Care Health Insurance Ltd, with Union Bank of India as the policyholder. The policy, valid till April 8, 2024, covered him, his wife Babita Gaur, and their two minor children. According to the complaint, Sharma’s wife slipped at home on May 22, 2023, suffering back, neck and leg pain. She was first taken to Jeevan Rekha Charitable Clinic and later shifted to Fortis Hospital, Noida, on June 5 as her condition worsened. “The doctor at Fortis Hospital directed to admit her in the hospital,” Sharma said, adding that his request for cashless treatment was denied, forcing him to pay Rs 1,53,709 out of pocket.After hearing both sides, the commission held that the patient was admitted on the advice of doctors at Fortis due to her deteriorating condition and was treated accordingly. Reiterating that the insurer could not override a doctor’s decision, the commission termed the claim rejection “unfair” and directed full reimbursement of the treatment cost.
