Can a Preliminary Hospital Note Affect Your Health Insurance Claim?

Being hospitalised can be a stressful experience, and navigating the complexities of health insurance claims can add to the burden. This blog post aims to address a common concern: can a preliminary note made during hospitalisation impact your health insurance claim settlement?

Real-Life Insurance Case Study: Insightful Takeaways for Providers and Policyholders

Understanding the Case: Mr. Shirish Bhatnagar

Mr. Shirish Bhatnagar, residing in Gautham Buddha Nagar, held a health insurance policy of Rs. 10 lakh from IFFCO Tokio, valid from November 5, 2010, to November 4, 2011. During the policy period, he was hospitalised due to an accident and incurred medical expenses of Rs. 9.87 lakh. However, his claim was unexpectedly rejected by the insurance company.

The Dispute: Preliminary Note vs. Evidence

IFFCO Tokio based their entire argument on a note made at the time of Mr. Bhatnagar’s admission to the hospital. The note stated that he was under the influence of alcohol when brought in the hospital. This note, however, lacked crucial supporting evidence:

• No Affidavit: There was no official statement from the hospital or doctor substantiating the claim.
• Missing Tests: No blood alcohol tests were conducted to confirm the note’s assertion.
• Absence of Quantification: The note did not specify the amount of alcohol allegedly consumed, if any.

Aggrieved, Mr. Bhatnagar approached the Consumer Redressal Commission who delivered the following verdict.

The Consumer Redressal Commission’s Verdict

Following an investigation, the Consumer Redressal Commission ruled in favour of Mr. Bhatnagar. The commission emphasised the absence of documented proof regarding his alleged intoxication and ordered IFFCO Tokio to settle the claim with interest from the date of the order. The Commission was unable to establish any substantiation to prove the fact that Mr. Bhatnagar was indeed intoxicated when brought to the hospital.

Key Takeaways:

This case highlights valuable lessons for both insurers and insured individuals:

For Insurers:

• Relying solely on preliminary notes without concrete evidence can be detrimental to claim adjudication.
• Thorough investigation and adherence to due process are crucial to ensure fair claim settlements.

For Insured Individuals:

• Be mindful of the information documented during hospitalisation, as it may impact your claim.
• Maintain clear communication with healthcare providers to ensure accurate and complete medical records.
• Remember that injuries or death arising from alcohol consumption are typically excluded from insurance coverage.

Conclusion:

Understanding the nuances of health insurance policies and claim processes is essential for both insurers and insured individuals. By exercising vigilance, fostering open communication, and upholding ethical practices, all parties involved can contribute to a smoother and more transparent claim settlement experience.