Plea seeking compensation for erectile dysfunction surgery rejected

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The Additional Thane District Consumer Disputes Redressal Forum has dismissed a man’s plea seeking compensation from a private insurance company for a surgery to treat erectile dysfunction. The forum ruled that drugs for the ailment are not covered by plans based on the National Medicare Guidelines.

The man obtained a rider policy from March 2016 to March 2018, which increased the sum assured, and a top-up policy from November 2017 to November 2019 from ICICI Lombard General Insurance Company. On January 22, 2018, he wrote to the company seeking a pre-authorisation letter for a penile implant surgery.

Rejecting the request, the company said, “Present ailment for which treatment is being availed is not covered; hence the cashless hospitalisation request is rejected.” He sent a legal notice to the company on February 1, 2018, but did not receive a reply. He underwent the surgery on February 16, 2018.

The man then moved the forum seeking ₹6.24 lakh with 18% interest from March 2018, ₹2 lakh as compensation, and ₹30,000 for the mental torture suffered.

The company’s counsel in its reply denied deficiency in service and unfair trade practice. The counsel said the request was rejected as the ailment is not covered under its mediclaim policy.

The Bench, comprising presiding member G.M. Kapse and member S.A. Petkar, said the case is based on terms and conditions of the policy, pre-authorisation letter, and medical certificate of the doctor. The Bench said, “Under the law, drugs to treat erectile dysfunction are excluded from the coverage unless they are used as a part of treatment approved by the Food and Drug Administration for a different situation.”

Dismissing the plea, the Bench said, “When the insurance policy was purchased by the complainant, he was aware of all the terms and conditions of the policy, including exclusion of ailments. Hence, the complainant is not justified to claim any amount.”

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Printable version | Jan 24, 2021 12:04:41 PM |

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