VISAKHAPATNAM: The Visakhapatnam District Consumer Forum-I has directed an insurance company to pay a consumer the amount deducted while settling his mediclaim, along with compensation and costs.
According to the case record, a resident of Maharanipeta in the city, A. Ratnaji Rao, subscribed to a mediclaim policy of the Oriental Insurance Company Ltd., by which he was entitled to reimbursement of any surgical operation, treatment and hospitalisation charges.
In view of his critical illness and overweight, chole cystectomy was perofmred after laparoscopy examination was done.
The medical superintendent also issued a certificate stating that as the laparoscopy procedure was not feasible, open chole cystectomy was done.
After the surgery, the complainant lodged a claim for Rs.39,013.87 but the mediclaim division of the insurance company sent the amount after deducting Rs.3,500.
The complainant issued a legal notice and later filed a complaint (557/2007) seeking repayment of the amount deducted illegally along with compensation for mental agony and cost of the complaint.
The opposite party (OP) in its counter said that the complainant was not entitled to the cost of instruments or the laparoscope charges as he did not undergo that procedural surgery but took open chole cystectomy treatment and therefore was not entitled to laparoscope charges.
In their recent judgement, president of the Forum-I Y. Dhilleswara Rao and member D. Suseela, noted that the laparoscopic examination was done in view of the acute calculus problem.
But due to certain conditions of the consumer, laparoscopic procedure was found not feasible and as such open chole cystectomy was done, they observed.
Noting that the definition of the surgical operation was wide and comprehensive and the manual or operative procedures for correction of deformities, defects, repair of injuries, diagnosis and cure of disease would not come within the definition of surgical operation, they felt repudiation of Rs.3,500 was without basis.
In the result, the OP was directed to pay Rs. 3,500 along with Rs. 1,000 as compensation for mental agony and another Rs. 1,000 towards costs.