The M.P. State Consumer Disputes Redressal Commission has clarified that insurers cannot mechanically deny mediclaim claims for intravitreal injections on the sole ground of non-hospitalization beyond 24 hours when medical certification confirms the necessity of in-patient care. This ruling reinforces the principle that policy interpretation must align with clinical reality, not rigid textual conditions.
Background & Facts
The Dispute
The complainant, Rahul S/o Basant Kumar Baheti, held a mediclaim policy No. 153500/48/2015/2538 issued by The Oriental Insurance Company Ltd. for himself, his wife, and his parents, effective from 27.03.2015 to 26.03.2016. He paid a premium of Rs. 34,801. His mother, Smt. Maya Devi, was diagnosed with Left Eye CNVN (Wet AMD) and required regular intravitreal injections of Lucentis (Accentrix) as part of her treatment.
Key Facts
- The complainant’s mother received intravitreal injections on the following dates: 02.09.2015, 02.10.2015, 03.11.2015, 29.01.2016, and 03.03.2016.
- On 02.09.2015, she was administered Lucentis at Retina Specialty Hospital, Indore, and was admitted for one day due to post-injection discomfort, as certified by Dr. Arun Bhargava, Chief Vitreo-retinal Surgeon (Exhibit C-10).
- On subsequent dates (02.10.2015 onwards), she received the same injection and was discharged within 2 hours as she remained comfortable, with no need for overnight stay.
- The complainant submitted claims for all five treatments, attaching medical records, discharge summaries, and the treating doctor’s certificate.
- The Insurance Company rejected all claims on 18.09.2015 and again on 21.10.2015, citing Clause 2.17 of the policy, which requires minimum 24-hour hospitalization for reimbursement.
- The insurer claimed that intravitreal injections are OPD procedures and hospitalization was unnecessary.
Procedural History
- 27.03.2015: Mediclaim policy issued by The Oriental Insurance Company Ltd.
- 02.09.2015: First injection administered; mother admitted for one day.
- 18.09.2015: First claim rejected by insurer.
- 21.10.2015: Second rejection of claim.
- 20.12.2016: District Consumer Disputes Redressal Commission, Khandwa, dismissed the complaint (Complaint No. 82/2016).
- 22.01.2017: Appeal filed before the M.P. State Consumer Disputes Redressal Commission (Appeal No. 225/2017).
- 15.07.2026: Judgment delivered by the State Commission.
Relief Sought
The complainant sought: (1) reversal of the District Commission’s order; (2) payment of hospitalization expenses incurred on 02.09.2015; (3) reimbursement of expenses for all other injections; and (4) interest and costs.
The Legal Issue
The central question was whether an insurer can deny reimbursement under a mediclaim policy solely on the ground that hospitalization did not exceed 24 hours, when a qualified medical professional certifies that in-patient admission was clinically necessary for the administration of an intravitreal injection.
Arguments Presented
For the Appellant
Learned counsel for the appellant argued that the treating doctor’s certificate (Exhibit C-10) clearly stated that on 02.09.2015, the patient required hospital admission due to post-injection discomfort, making in-patient care medically necessary. She emphasized that the policy’s exception clause for specified procedures allows for shorter hospitalization, and that intravitreal injections, though typically OPD, may require hospitalization under clinical circumstances. She cited the principle that insurance policies must be interpreted in favor of the insured in case of ambiguity.
For the Respondent
Learned counsel for the Insurance Company contended that intravitreal injections like Lucentis are universally recognized as outpatient procedures under medical guidelines and policy terms. He argued that no hospital bed tickets or admission records were produced to substantiate the claim of 24-hour hospitalization on 02.09.2015, and that the doctor’s certificate was insufficient to override the policy’s explicit 24-hour condition.
The Court's Analysis
The State Commission examined Clause 2.17 of the policy, which defines hospitalization as admission for a minimum of 24 consecutive hours, "except for specified procedures/treatments, where such admission could be for a period of less than 24 consecutive hours." While the policy does not explicitly list intravitreal injections as an exception, the Commission held that the phrase "specified procedures" is not exhaustive and must be interpreted in light of medical necessity.
"It cannot be denied that as per certificate issued by Dr. Arun Bhargava... the complainant's mother was administered injection and she was uncomfortable. Hence she was admitted for one day."
The Commission noted that the insurer’s rejection was based on a blanket assumption that all intravitreal injections are OPD procedures, without considering individual clinical conditions. It emphasized that the treating specialist’s certification, based on direct patient observation, carries greater weight than generic policy interpretations. The Commission further observed that the District Commission erred in assuming that hospitalization on 02.09.2015 was for 24 hours, when the evidence showed it was for one day due to medical necessity.
The Court held that the insurer’s refusal to pay for the 02.09.2015 treatment was arbitrary and constituted deficiency in service under the Consumer Protection Act, as the claim was supported by credible medical evidence.
The Verdict
The appeal was partly allowed. The State Commission set aside the District Commission’s order dated 20.12.2016. The Insurance Company was directed to pay hospitalization expenses incurred on 02.09.2015, with interest at 6% per annum from the date of repudiation (18.09.2015) until actual payment. The Company was also directed to pay costs of Rs. 2,500. Compliance was mandated within six weeks from the date of judgment.
What This Means For Similar Cases
Medical Certification Overrides Policy Presumptions
- Practitioners must now argue that insurer rejections based on rigid hospitalization thresholds are invalid when supported by a treating physician’s certification of medical necessity.
- In mediclaim disputes involving injections, infusions, or day-care procedures, the burden shifts to the insurer to prove the procedure was truly non-hospitalizable, not to the insured to prove it was.
Policy Exceptions Are Contextual, Not Exhaustive
- Insurers cannot rely on a closed list of "specified procedures" to deny claims; the exception clause must be interpreted dynamically based on clinical judgment.
- Legal challenges should cite this judgment to argue that policy language must yield to medical reality, especially in ophthalmology, oncology, and neurology treatments.
Documentation Strategy for Claimants
- Always obtain and submit a signed, stamped certificate from the treating specialist detailing: (a) the procedure, (b) reason for admission, (c) duration of stay, and (d) clinical justification.
- Even if discharge occurs within hours, the certificate must explicitly state that admission was required for safety or monitoring.
