Tim was hospitalised from 31 July to 10 August 2024 for severe congestive cardiac failure secondary to dilated cardiomyopathy. What began as an urgent admission requiring close medical supervision later became the subject of a dispute when his insurer declined his claim for hospitalisation benefits.

The insurer maintained that the full 11-day stay was not medically justified, as his condition could have been safely managed on an outpatient basis.

FINDINGS

During the admission, Tim received intravenous therapy and anticoagulants treatment, including warfarin from 31 July 2024 to 03 August 2024.

Medical records showed that warfarin was discontinued after 3 August, and no further complications, interventions, or additional investigations were recorded thereafter that could justify continued inpatient treatment.

Although multiple cardiac medications were continued until discharged, the case manager noted that from 4 August onwards, the treatment and monitoring could reasonably have been provided on an outpatient basis. The remaining period of hospitalisation appeared to involve non‑acute observation without clear medical justification.

OUTCOME

The case manager recommended that the FSP consider covering the first five days of admission, as these were medically necessary and reasonable for initial stabilisation and monitoring, while the subsequent days did not meet the threshold for inpatient care.

Following this assessment, the insurer agreed to revise its decision and partially settle the claim for the medically justified period of five days. In addition, the insurer agreed to assess related pre- and post-hospitalisation benefits, as well as the daily cash allowance, for the five days of necessary admission.