‘Patient not liable for hospital’s civic lapses’

Vadodara: Holding that a patient cannot be penalised for a hospital's failure to comply with registration norms, a city consumer forum has directed an insurance company to settle a mediclaim along with compensation and legal costs, reports Tushar Tere. The Vadodara District Consumer Disputes Redressal Commission passed the order on a complaint filed by Indradutt Pandya (63) who had purchased a policy from The New India Assurance Company Ltd in 2003. Pandya underwent cataract surgery in 2022 and filed a claim of Rs 44,700, which was rejected by Paramount Health Services and Insurance TPA Pvt Ltd, engaged by the insurer.Challenging the rejection, Pandya approached the consumer commission in May 2023, seeking the claim amount with 18% interest, Rs 25,000 for mental harassment and Rs 15,000 towards legal expenses. The insurance company argued that the claimant failed to provide certain details about the hospital and contended that the facility was not registered under Vadodara Municipal Corporation norms. The insurance company also pointed out that the hospital did not meet the requirement of being a 10-bed facility as per VMC circulars issued in 2016–17 and 2020–21.After hearing both sides, the commission observed that while hospital registration may be mandatory under civic rules, the contractual obligation lies between the insurer and the policyholder. It held that the patient cannot be denied reimbursement on grounds related to the hospital's compliance with municipal 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.The forum further noted that the treating doctor was certified and that rejecting the claim on technical grounds, including non-submission of certain hospital documents, was unreasonable. It added that the purpose of an insurance policy is to provide financial support during medical emergencies, and denying claims on conditions not clearly communicated to the policyholder is unjust.The commission directed the insurer to pay Rs 44,700 to Pandya, along with Rs 2,000 for mental harassment and Rs 1,000 towards legal costs.