Hospitalization for evaluation

Can a claim be repudiated on the basis that hospitalization was done for evaluation only?

Yes if the insured is not suffering from any illness but still gets hospitalized to avail of tests in order to ascertain whether or not he/she is suffering from any illness.

On the other hand, if you are ill but it is not known what is the cause of the illness, then in that case, if the insured is hospitalized, and tests are done to determine the cause of the suffering, in this case, all the tests may be paid for.

In Subhash Goyal vs. Oriental Insurance[1], the insured was admitted in an emergency condition, with the symptoms of urinary retention and fever for last five days.

Tests were conducted to determine the cause of the disease. The insurer denied the claim, reasoning that hospitalization was for evaluation purposes only.

The Ombudsman ruled in the insured’s favour, stating that it was highly improper for the insurer to reject the claim.

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[1] CHD-G-050-1718-0427;