Health India Medicine

Do  not deny  medical  claim to the  patient  if he was discharged the  same  day :CDR Commission

By  our  legal correspondent

Kochi, Oct 22 (IVC)  The Ernaklam  District Disputes  Redress  Commission   ordered  that  a  medical procedure   cannot  be  excluded from  the  terms of  an insurance  policy simply because the  patient  is  discharged the  same  day  due  to  advanced  technology.

                The Commission  made  the observation here  recently  while  dismissing  an  insurance  company’s denial  of  claim  to  a  policy  holder  to  be  based  on false grounds  amounting to  unfair trade  practice. The  Commission issued  the  verdict on a petition  filed  by  Johny  Milton of  Maradun in  the District  against  Universal  Sompo General  Insurance  Company Limited. The  complainant  had insurance  policy with a  coverage of  Re  1 lakh  (One lakh rupee only)  including for  his  parents.

                In  March 2021,  his  mother  was  diagnosed with  myopic choroid nonvascular  membrane in her left  eye and  received   treatment  at  an  eye  hospital.

                The  company,  however rejected the  claim saying that   the  procedure was  categorized  incorrectly  and not  to cover under  the  day-  care procedure  list.

                The Commission   found  the  company  to  have acted ignoring the  guidelines of  the  Insurance  Regulatory  Authority  of  India (IRDA) ,  which  explicitly  included ‘intravitreal injections’

A procedure  that  should  not   be   excluded  in  health  insurance policies.  Furthermore, the  commission also found  the  company  to  have  allowed a  claim for  similar procedure  without   objection showing  that  its  stand on  the  issue  was  inconsistent.

                Consequently,  the  commission directed the  insurance  company  to  reimburse to  the  complainant  with  Rs  27,720  as  compensation as deficiency  in  service and  mental agony.   Besides,  the  company   was  also  asked  to  pay  the  complainant Rs 10,000  towards  the cost  of  the  proceedings. 

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