Insurance firm has to pay for turning a blind eye towards client

Taking a dim view of the stance adopted by the insurance firm in the matter, the South Mumbai Consumer Disputes Redressal Commission has directed The New India Assurance Company Ltd to reimburse over Rs. 2.3 lakh to a Malabar Hill-based woman for an eye surgery she underwent in 2008. Rupam Khattau, who lives at Dongershi Road, had submitted a claim, which was rejected, as the treatment she underwent was allegedly ‘unproven' and not surgical in nature.

Representation pic

According to Khattau's complaint, she had purchased mediclaim for the period June 20, 2008 to June 19, 2009, with a cover of Rs 5 lakh and a premium of Rs 20,396. During the subsistence of the policy, Khattau suffered from Classic Choroidal Neovascular Membrane, an abnormal growth in her right eye. She underwent surgery at Infiniti Eye Hospital and continued to take injections for three months. Her total expenses for the operation amounted to Rs 2,34,866.

When Khattau submitted a reimbursement claim though, the insurance firm rejected it on December 31, 2008. The first reason cited was that the treatment undergone by Khattau was ‘unproven' - according to the mediclaim policy, the company was not liable to pay back expenses for a treatment not recognised by the Indian Medical Council. The second reason given was that the procedure was an OPD treatment, falling outside the purview of the insurance policy.

Wide of the mark
Refuting both these contentions, advocate Subhash Chaubal, appearing on Khattau's behalf, produced letters by two doctors - Cyrus Shroff, president of Vitreo Retina Society of India and Lalit Verma, Honorary General Secretary, All India Ophthalmological Society. The letters stated that the procedure was surgical in nature, requiring the use of surgical hand disinfection, sterile gloves, a sterile drape, etc. It was not an OPD treatment.

Before approaching the consumer court, Khattau had also appealed to the insurance ombudsman. In his award, he too had concluded that an ‘intravitreal injection' was a surgical procedure. The doctors' letters, which gave extensive descriptions of the method, also helped the court establish that Khattau's treatment was well-recognised, and therefore not ‘unproven', as contended by the insurance company.

A bench comprising president SB Dhumal and member SS Patil in its order passed on July 17 observed, "It is clear that opposite parties have wrongly repudiated claim of the complainant and it amounts to deficiency in service on the part of opposite parties." The bench directed the insurance company to reimburse the entire amount claimed by Khattau, along with 9 per cent interest per annum from December 31, 2008 onward, till the sum is finally paid to her.u00a0