Only doctor can decide line of treatment of a patient, NOT insurance company: Consumer Court

Vadodara: Stressing on the authenticity of medical treatment provided by a medical practitioner, a consumer court has made an incisive observation and held that only doctor can decide the line of treatment to given to a patient and not the insurance company. The court stressed upon treating doctor's opinion more truthful than third-party administrator (TPA) and ordered the firm along with TPA to pay the insured amount to a citizen.

The case relates to one Bhanvarlal Purohit and his wife, Pushpa who was suffering from cervical spondylosis. In January 2017, the patient was admitted to the Dadaji Hospital for three days as indoor-patient for examination and observation as she complained of cervical pain. Following the patient's discharge, Purohit(complainant) had claimed insurance of Rs 19457 from the National Insurance Company and TPA Paramount Health Services and Insurance.

However, post a month the TPA rejected the claim complying that 'no active line of treatment was given during hospitalization.'

Also Read: Mediclaim cannot be rejected if duplicate bills are submitted: Consumer Forum on doctors plea

The complainant then moved the Vadodara District Consumer Disputes Redressal Forum in August 2018 against insurer National Insurance Company and the TPA. He substantiated his application by submitting the discharge report along with the doctor's certificate that mentioned Pushpa's health condition and the treatment offered to her.

The complainant's advocate, Montu Pandya contended, "During hospitalization, the doctor prescribed x-ray, laboratory tests, several medicines, injections and consulting a physician. But the insurance company claimed that such treatment was not needed for treating cervical spondylosis and therefore they rejected the claim giving a reason that no active treatment was given."

After hearing the contention, the forum held that 'No insurance company can decide the line of the treatment to be given to a patient, only doctors can decide about the treatment."

The court further deliberated the evidence and observed that the TPA has given its opinion after examining the case papers only and stated, "Opinion of the doctor who treated the patient is more truthful than the TPA's opinion which is based on examination of case papers."

The insurance company has been directed to reimburse the complainant's claim along with 8 per cent interest and compensation of Rs 3,000, reports TOI

Also Read: Medical Insurance to refund MRI, pre-operation expenses under mediclaim : Consumer Panel