In a landmark ruling with significant implications for health insurance policyholders in Gujarat, the Vadodara District Consumer Disputes Redressal Commission (Additional) has held that a doctor's bedside visits during hospitalization are an essential part of medical treatment. Consequently, the fees for such visits must be reimbursed under an insurance claim. The forum rejected an insurer's deduction of these fees, terming them as 'extras'.
Background of the Case
The order was passed in response to a complaint filed by Jatinkumar Rana, whose son was diagnosed with viral hepatitis and admitted to a hospital in April 2023. Rana incurred medical expenses amounting to Rs 25,676 and submitted a claim to Aditya Birla Health Insurance Company Ltd, with whom he held a health policy. The insurer reimbursed only Rs 16,576, deducting the balance under various heads.
Complaint and Proceedings
Objecting to the deductions, Rana approached the consumer forum in August 2023, seeking payment of Rs 9,100 with 12% interest, along with Rs 5,000 each towards legal costs and compensation for mental agony. The insurance company did not file a reply before the commission.
The forum examined the medical bills and arguments placed on record. Dinesh Lalwani of Grahak Suraksha Jagruti Manch, which represented Rana, argued that a doctor's visit is necessary to monitor the patient's health and is an integral part of in-hospital treatment.
Forum's Observations and Order
While the commission deemed certain deductions, such as miscellaneous and registration charges, as reasonable, it faulted the insurer for excluding the doctor's visiting fees. The forum observed: "The opponent deducted Rs 2,000 towards visit charges for two days. When a patient is in hospital, it is necessary to check if the patient's health is improving. The complainant is entitled to get visit charges of Rs 2,000."
The commission directed the insurer to pay the Rs 2,000 for visit charges and Rs 6,000 deducted for room and nursing charges. Additionally, it ordered payment of Rs 1,000 as compensation for mental agony and Rs 2,000 towards legal costs.
Implications
This ruling sets a precedent for health insurance claims in Gujarat, clarifying that expenses directly related to patient care during hospitalization, including doctor visit fees, cannot be arbitrarily excluded by insurers. Policyholders can now seek reimbursement for such essential components of medical treatment.
