A consumer forum in Vadodara has ruled in favour of a policyholder, stating that a patient cannot be penalised for a hospital’s failure to meet registration rules, reported Times of India.
The forum directed the company to settle the mediclaim along with compensation and legal costs.
The order was passed by the Vadodara District Consumer Disputes Redressal Commission on a complaint filed by Indradutt Pandya, 63. He had purchased a policy from The New India Assurance Company Ltd in 2003.
Pandya underwent cataract surgery in 2022 and later filed a claim of Rs 44,700. by Paramount Health Services and Insurance TPA Pvt Ltd, which was acting on behalf of the insurer.
Following the rejection, Pandya approached the consumer commission in May 2023. He sought the claim amount along with 18% interest, Rs 25,000 for mental harassment and Rs 15,000 towards legal expenses.
The insurance company argued that the claim could not be processed as the
It also said that the hospital was not registered under the Vadodara Municipal Corporation rules.
Further, the insurer pointed out that the hospital did not meet the requirement of being a 10-bed facility, as mentioned in VMC circulars issued in 2016–17 and 2020–21.
After hearing both sides, the commission said that while hospital registration may be required under civic rules, the contract is between the insurer and the policyholder.
It held that a patient cannot be denied reimbursement based on issues related to the hospital’s compliance with local regulations.
“The requirement of registration is a matter between the hospital and the VMC. The treatment taken by the complainant does not become illegal,” said advocate Gaurang Bumiya, who represented Pandya, as quoted in the Times of India report.
The forum also noted that the doctor who treated Pandya was certified. It said that rejecting the claim on technical grounds, including the non-submission of certain hospital documents, was not reasonable.
It added that the purpose of an insurance policy is to provide financial support during medical emergencies. Denying claims based on conditions that were not clearly shared with the policyholder is unfair.
The commission directed the insurer to pay Rs 44,700 to Pandya. It also ordered an additional Rs 2,000 for mental harassment and Rs 1,000 towards legal costs.
The ruling makes it clear that policyholders should not suffer due to lapses by hospitals, especially when the treatment itself is valid and carried out by a qualified doctor.