An insurance company denied the claim of an insured whose son had undergone surgery in both eyes to save his constantly deteriorating vision. The company denied the responsibility saying the surgery was not a medical procedure but cosmetic in nature.
The Consumer Forum, however, thought differently.
The company has been directed by the Central District Consumer Disputes Redressal Forum to pay Rs.1.11 lakh to the complainant who spent the same amount on the ICL implantation of his son, who was diagnosed with pathological myopia in which the vision is lost gradually.
The complainant, Rajan Malhotra, had insurance with the New India Assurance Company. When he sought a refund of the claim, the company denied the same saying the surgery was a cosmetic procedure and was, therefore, not covered in the policy.
Before the forum also, it maintained that the claim was not payable and rightly rejected. It also said that the claim of Mr. Malhotra had been put before a medical board too which opined it to be a cosmetic surgery.
The forum said that the company had not denied that ICL implantation was a recognised medical procedure being undertaken in many cases for years now.
It also noted that insurers these days are mostly denying the claims on one pretext or the other. “Since it is a recognised medical procedure, by no stretch of imagination can it be termed a cosmetic surgery,” the Bench of president Rakesh Kapoor and S. N. Shukla said.
“The company has failed to place on record the constitution of the medical board in order to see whether it comprised eye surgeons and as to how they had reached a conclusion that the procedure undertaken amounted to a cosmetic surgery. In the absence of such evidence... we are inclined to hold that the repudiation of the claim was unjustified and uncalled for,” the forum said. Besides the claim, the company has been asked to pay Rs.10,000 to the complainant towards the cost of litigation.
The Consumer Forum, however, thought differently.
The company has been directed by the Central District Consumer Disputes Redressal Forum to pay Rs.1.11 lakh to the complainant who spent the same amount on the ICL implantation of his son, who was diagnosed with pathological myopia in which the vision is lost gradually.
The complainant, Rajan Malhotra, had insurance with the New India Assurance Company. When he sought a refund of the claim, the company denied the same saying the surgery was a cosmetic procedure and was, therefore, not covered in the policy.
Before the forum also, it maintained that the claim was not payable and rightly rejected. It also said that the claim of Mr. Malhotra had been put before a medical board too which opined it to be a cosmetic surgery.
The forum said that the company had not denied that ICL implantation was a recognised medical procedure being undertaken in many cases for years now.
It also noted that insurers these days are mostly denying the claims on one pretext or the other. “Since it is a recognised medical procedure, by no stretch of imagination can it be termed a cosmetic surgery,” the Bench of president Rakesh Kapoor and S. N. Shukla said.
“The company has failed to place on record the constitution of the medical board in order to see whether it comprised eye surgeons and as to how they had reached a conclusion that the procedure undertaken amounted to a cosmetic surgery. In the absence of such evidence... we are inclined to hold that the repudiation of the claim was unjustified and uncalled for,” the forum said. Besides the claim, the company has been asked to pay Rs.10,000 to the complainant towards the cost of litigation.
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