Homoeopath’s Certificate No Ground for Insurance Mediclaim Rejection

The Surat District Consumer Disputes Redressal Commission (Additional) has directed Aditya Birla Health Insurance Company Ltd to reimburse ₹73,000 in hospitalisation expenses to a policyholder after finding that the insurer had failed to substantiate its grounds for rejecting the mediclaim. The commission also awarded ₹3,000 as compensation for mental agony and harassment and ₹2,000 towards litigation expenses.

According to the report, the complainant, Nishant Kothari, held a health insurance policy covering the period from May 14, 2018, to May 13, 2019. He was admitted to Unique Hospital from September 2 to 6, 2018, for abdominal pain, incurring treatment expenses of ₹73,000.

After submitting a claim with the necessary documents, Kothari’s reimbursement request was rejected by the insurer. The grounds cited included alleged non-disclosure of a pre-existing disease, a waiting-period clause and a permanent exclusion clause. He subsequently approached the consumer commission, seeking reimbursement and compensation for the hardship caused by the rejection.

During its examination of the records, the commission noted that a certificate relied upon by the insurer had been issued by a homoeopathic doctor, whereas the hospital’s discharge summary indicated that the patient had received treatment at a facility without a homoeopathy department.

The commission also observed that the proposal form did not clearly establish whether the policyholder had specifically been asked about the illness for which he subsequently underwent treatment.

Crucially, the insurer failed to produce sufficient evidence to establish that the policyholder had concealed a pre-existing disease or that the claim was inadmissible under the applicable waiting-period provisions. The commission consequently directed the insurer to pay the hospitalisation expenses, along with the additional amounts awarded.

The decision highlights the importance of examining the relevance, reliability and evidentiary value of medical documents in insurance disputes. An insurer’s decision to reject a claim must be supported by adequate evidence and a reasoned application of the relevant policy terms.

For homoeopathic practitioners, the case also underscores the importance of maintaining accurate clinical records and issuing certificates that clearly reflect the purpose for which they are prepared, the findings documented and the practitioner’s actual involvement in the patient’s care.

The ruling should, however, be understood in the context of the specific dispute. It does not establish that every certificate issued by a homoeopathic doctor is sufficient evidence for every insurance claim, nor does it mean that insurers are precluded from examining medical records or enforcing valid policy exclusions.

The broader principle remains that decisions affecting policyholders must be based on relevant evidence, clearly established policy conditions and a fair assessment of the circumstances of each case.