Order to pay mediclaim Consumer Notes

K. Vijaya Bhaskara Reddy

Insurance company pulled up for denying just claims by obtaining expert opinions that suited its needs

HYDERABAD: The State Consumer Disputes Redressal Commission has criticised the insurance companies for denying the just claims of policyholders on one ground or the other by obtaining expert opinions to suit their needs. It set aside the verdict given by the Nellore District Forum in favour of the New India Assurance Company in a particular case.

The case pertains to one K. Ramachandra Rao, resident of Atmakur, who took a mediclaim policy for him and his family from the company. His son underwent the Lasik laser eye surgery due to irregular astigmatism, a disease that hurts the eyes and causes refraction problems, which cost him Rs. 24,367.

When Mr. Rao requested for the mediclaim in 2005, the company rejected it by stating that it was a cosmetic surgery based on the opinion of its panel doctor. It rejected to consider the opinion of the specialist doctor who conducted the operation. The policy holder approached the District Forum seeking payment of Rs. 24,367 with annual interest of 24 per cent from the date of the claim - Rs. 25,000 towards damages and court costs.

The District Forum gave a verdict in favour of the company in 2006. Contesting this judgement in the State Commission, the complainant cited noted medical dictionaries, which clearly stated that irregular astigmatism was a disease and needs surgery. The Commission wondered why the company preferred the opinion of its own panel doctor to that of a specialist.

It observed that the panel doctor neither elaborated, nor substantiated his opinion and said he could have cross checked with the specialist before forming his opinion. The Commission further commented that the insurance companies were trying to avoid paying up by taking into consideration the opinion of their panel doctors, who were its own appointees.

It modified the district forum’s decision and directed the company to pay Rs. 24,367 with interest of 9 per cent per annum from August 16, 2005 when the claim was made with costs of Rs. 2,000. It also ordered payment of Rs. 10,000 towards compensation since the claim was repudiated without any justification and the time for compliance was one month.

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