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.