GURDEEP SINGH F/o. Kuldeep singh v. STAR HEALTH AND ALLIED
INSURANCE COMPANY LIMITED Through its Managing director
District Consumer Disputes Redressal Commission (Jul 29, 2026)
SUMMARY
Factual and Procedural Background
The complainant purchased a Family Health Optima Insurance Plan in 2021 (Policy No.
initially P/231115/01/2022/010702; later Policy No. 11240350375902) covering four
family members, with consecutive renewals thereafter. On 10.08.2023 the complainant's
son, Master Agam Kahlon, became seriously ill and was admitted to Zonal Hospital,
Dharamshala (10.08.2023– 12.08.2023) and thereafter to City Hospital, Matour, Kangra
(12.08.2023– 17.08.2023). Diagnosis: Acute Febrile Illness with Thrombocytopenia and
Transaminitis. The complainant incurred medical expenses (bills summarized as
Rs.58,729/-) and submitted a reimbursement claim (Claim No.
CIR/2024/231115/0649164). The opposite parties repudiated the claim by letter dated
20.09.2023 on the ground that hospitalization was not medically necessary (reliance on
Code Excl 36). The complainant filed the consumer complaint (instituted 12.03.2025).
Final hearing was on 09.07.2026 and the order was pronounced on 29.07.2026.
Legal Issues Presented
1. Whether the hospitalization of the insured (Master Agam Kahlon) from 12.08.2023 to
17.08.2023 was medically necessary.
2. Whether the opposite parties' repudiation of the claim under Code Excl 36 (exclusion for
hospitalizations not medically necessary) amounted to a valid denial or constituted
deficiency in service. 3. Whether the complainant is entitled to reimbursement of the claimed medical expenses
and ancillary relief (interest, compensation, litigation costs).
Arguments of the Parties
Complainant's Arguments
The son was seriously ill and was hospitalized (initially at Zonal Hospital from
10.08.2023; thereafter at City Hospital from 12.08.2023 to 17.08.2023) on the advice of
treating doctors.
Medical records and discharge summaries (including certificate by Dr. Venkateshan
Madhavan) support the need for hospitalization.
The complainant incurred total expenses of Rs.58,729/- and sought reimbursement,
interest and compensation; he filed an affidavit corroborating the admissions and
treatment. Opposite Parties' Arguments
Admitted policy subsistence and renewals but denied deficiency in service.
Based on internal scrutiny by their in- house medical team, concluded that the
hospitalization was not medically necessary and the patient could have been managed
on an outpatient basis.
Repudiated the claim under Code Excl 36 of the policy.
Produced a bill assessment sheet (Annexure R-8) reflecting a lower amount
(Rs.33,727/-), though the sheet is unsigned and unsupported by affidavit.
Table of Precedents Cited
No precedents were cited in the provided opinion.Court's Reasoning and Analysis
The court reviewed the policy history, hospitalization records, discharge summaries and
oral/written evidence. It relied on the treating doctor's certificate (Annexure A-40) and the
complainant's affidavit (Ext. CW-1) showing continuous admission beginning 10.08.2023
and treatment with IV fluids and IV antibiotics. The court noted a borderline blood
pressure reading (100/60– 102/60 mmHg) and held that indoor treatment was necessary.
The court observed that the opposite parties did not file any affidavit from their medical
team to support their in- house conclusion and that the insurer's medical team cannot
substitute the treating physician's judgment on medical necessity. The unsigned and
unaffirmed bill assessment (Annexure R-8) was given no weight. On the evidence, the
complainant's proofs of expenditure were accepted as superior.
Holding and Implications COMPLAINT ALLOWED
Direct consequences ordered by the court:
The opposite parties are jointly and severally directed to pay Rs.58,729/- to the
complainant.
Interest at 9% per annum to be paid from the date of the complaint until realization.
Compensation of Rs.20,000/- awarded to the complainant for mental harassment.
Litigation costs of Rs.15,000/- awarded to the complainant.
Pending applications disposed of; copies of the order to be provided free of cost and
uploaded on the Commission's website; file consigned to record room.
No broader legal precedent or novel legal principle was declared in the opinion; the
decision addresses the parties' dispute and the direct relief ordered above.ALLOWED
BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL
COMMISSION KANGRA AT DHARAMSHALA, H.P.
Date of Institution: 12.03.2025 Date of final hearing: 09.07.2026 Date of
Pronouncement: 29.07.2026 Consumer Complaint No.-DC/18/CC/75/2025
IN THE MATTER OF
Gurdeep Singh S/o Sh. Kuldeep Singh , R/o Deep Bhawan, Sarswati Nagar, Upper
Barol, Dharamshala, Tehsil Dharamshala, District Kangra, H.P. (Through: Mr.
Rakesh Mehra, Advocate)
….........Complainant
Versus
1. Star Health & Allied Insurance Company Limited, Registered & Corporate
Office: 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai
- 600034. Through its Managing Director.
2. Star Health & Allied Insurance Company Limited, Branch Office: E-12/8, 4th
Floor, Shree Vrindaven Tower, Sanjay Palace, Agra Town, Uttar Pradesh - 282002.
Through its Branch Manager.
(Through: Ms. Disha Gupta, Advocate)
……....Opposite Party(s) CORAM:
President: Mr. Hemanshu Mishra Members: Ms. Arti Sood & Sh. Narayan Thakur
Present:- Mr. Rakesh Mehra, Ld. counsel for complainant. Ms. Disha Gupta, Ld.
counsel for opposite parties.PER: Mr. Hemanshu Mishra, President :-
O R D E R
Facts giving rise to filing of this complaint are that upon the active persuasion of an
authorized agent of the OPs, complainant purchased a 'Family Health Optima
Insurance Plan' in the year 2021. The policy was initially registered under
No.P/231115/01/2022/010702 for the period from 11-08-2021 to 10-08-2022,
covering four family members: the complainant, his wife Smt. Ritu Singh and his
two sons, Master Agam Kahlon and Master Kanish Kahlon. The coverage was
subsequently renewed continuously over the following years, with the premium
increasing accordingly. It is averred that on 10th August 2023, the complainant's
son, Master Agam Kahlon, fell severely ill with a running high fever and intense
throat pain. He was initially rushed to the Zonal Hospital, Dharamshala. Finding no
substantial improvement there, he was discharged on request on 12-08-2023 and
immediately admitted to City Hospital, Matour, District Kangra, H.P., on the explicit
medical advice of the treating doctors. The patient remained hospitalized as an
indoor patient from 12-08-2023 to 17.08.2023. The final medical diagnosis recorded
in the discharge summary was Acute Febrile illness with Thrombocytopenia (TCP)
and Transaminitis. The complainant incurred a total expenditure of Rs.58,729/-. The claim intimation was sent via email on 15.08.2023 and a formal reimbursement
request with all relevant cash memos and lab reports followed. However, the OPs
arbitrarily repudiated the claim vide a letter dated 20-09-2023. Left with no option, the complainant filed this complaint seeking reimbursement of
Rs.58,819/- along with 12% interest, Rs.50,000/- as compensation for mental
harassment and Rs.20,000/- as litigation expenses.
2. Upon notice, opposite party(s) appeared through counsel and contested the
complaint by filing reply. On merits, while admitting the subsistence and
consecutive renewals of the Family Health Optima Insurance policy, the OPs
vehemently denied any deficiency in service. The core defense raised by the OPs is
that upon internal scrutiny of the medical files and investigation charts by their inhouse medical team, it was concluded that the patient's hospitalization was not
medically necessary. The OPs contended that the patient's vital parameters and
investigation reports were within normal limits and that the medical condition could
have safely been managed at home on an OPD basis. Consequently, the claim was
rejected under Code Excl 36 of the policy terms and conditions, which explicitly
excludes coverage for hospitalizations deemed medically unnecessary.
3. The complainant has filed rejoinder denying the contents of the reply filed by
opposite party(s) and reiterating those of complaint. 4. The parties were called upon to produce their evidence in support of their
contentions and accordingly the parties have adduced their respective evidence.
5. We have heard learned counsel for the parties and also gone through the case file carefully.
6. Admittedly, the complainant purchased a Family Health Optima Insurance Plan
from the opposite party on 11.08.2021. The said policy was effective w.e.f.
11.08.2021 to 10.08.2022. Thereafter, the complainant renewed the said policy on
11.08.2022, 11.08.2023, and 11.08.2024. It is also not disputed that the
complainant's son, Master Agam Kahlon, remained hospitalized w.e.f. 12.08.2023 to
17.08.2023 in City Hospital, Kangra, and upon intimation by the complainant,
Claim No. CIR/2024/231115/0649164 was registered against Policy No.
11240350375902.
7. The opposite party, based upon the opinion of their medical team, repudiated the
claim on the ground that the insured patient could have been treated as an outpatient,
and hospitalization of the insured patient was not warranted for the above diagnosis.
They referred to Code Excl 36 of the above policy, which states that the company is
not liable to make any payment under this policy in respect of any hospitalization
that is not medically necessary or does not warrant hospitalization. Consequently,
the opposite party repudiated the claim on 20.09.2023. 8. A perusal of the record reveals that vide Annexure A-40, Dr. Venkateshan
Madhavan, M.D. Medicine, City Hospital, Kangra, certified that Master Agam was
diagnosed with acute febrile illness and thrombocytopenia. On examination, his BP
was borderline at 100/60 mmHg. Thus, he was hospitalized from 12.08.2023 to 17.08.2023 and was managed
with IV fluids and IV antibiotics for the same.
9. On 20.10.2023, the complainant submitted a written request to the opposite party
to review the rejection of the claim, further stating that the patient was admitted
from 10.08.2023 to 12.08.2023 in Zonal Hospital, Dharamshala as well. This is
further corroborated by the affidavit filed by the complainant (Ext. CW-1), wherein
he specifically deposed that his son fell seriously ill with a high fever and severe
throat pain, and was admitted to the Zonal Hospital on 10.08.2023. As there was no
improvement and his health deteriorated, the son was discharged on request on
12.08.2023, and on the same day, was admitted to City Hospital, Matour, District
Kangra, H.P. on the advice of the treating doctors for proper and regular medical
management to recover from the illness, remaining admitted until 17.08.2023. The
discharge summary of Zonal Hospital, Dharamshala is Annexure A-5, wherein the
brief history mentions fever for five days accompanied by throat pain, rhinorrhea,
and headache. BP was recorded as 102/60 mmHg, which aligns with the certificate
Annexure A-40. 10. We are of the opinion that the patient required hospitalization on 12.08.2023, as
he had been continuously admitted since 10.08.2023 at the Zonal Hospital, and
because his blood pressure was recorded at 102/60 mmHg (which was borderline),
indoor hospital treatment was necessary. The opposite party has not attached any affidavit from any
member of their medical team. Even otherwise, it is not for the insurance
company's medical team to decide who should be treated as an indoor patient or who
should be treated at home for any illness. It is the treating doctor who must make
that decision, and once he has issued a certificate stating that treatment was required
in the hospital, the repudiation of the claim is completely wrong, illegal, and
amounts to a deficiency in service.
11. The complainant has attached medical bills for the entire expenditure incurred
during the treatment; the summary is Annexure A-7, and the bills are Annexures
A-8 to A-30 & A-39, totaling Rs. 58,729/-. On the other hand, the opposite party has
annexed Annexure R-8 (Bill Assessment Sheet - Member Payment), which reflects
an amount of Rs. 33,727/-; however, the said bill assessment sheet is unsigned. No
affidavit in support of Annexure R-8 has been filed. Even in his affidavit (Ext.
OPSW- 1), Mr. Sumit Kumar Sharma, Sr. Manager, has not uttered a single word
regarding Annexure R-8. The complainant has produced superior evidence, having deposed that he incurred a total expenditure of Rs. 58,729/-. Hence, the complaint
deserves to be allowed.
12. Accordingly, the complaint is allowed, and the opposite parties are jointly &
severally directed to pay an amount of Rs.58,729/- to the complainant, along with
interest @ 9% per annum from the date of the complaint until its realization. Apart from this, the opposite parties are jointly and
severally directed to pay compensation to the complainant to the tune of
Rs.20,000/-, besides litigation costs quantified at Rs.15,000/-
13. Applications pending, if any, stand disposed of in terms of the aforesaid order.
14. A copy of this order be provided to all the parties free of cost as mandated by the
Consumer Protection Act, 1986/2019. The order be uploaded forthwith on the
website of the Commission for the perusal of the parties.
15. File be consigned to record room along with a copy of this order.
(Hemanshu Mishra)
President
(Narayan Thakur) (Arti Sood)
K.D* Member Member
