CERS helps a harried lady doctor get reimbursement for eye surgery from Oriental Insurance

Ahmedabad,May 8th , 2013

Consumer Education & Research Society (CERS) once again came to the rescue of a harassed consumer. This time an Ahmedabad-based lady doctor who was denied reimbursement for an eye surgery by her insurance company.

As per the case details, Dr. Diksha Sawant*, a resident of Bopal area of the city, had purchased a health insurance policy from The Oriental Insurance Co. Ltd about 20 years ago and it was renewed every year since then. The policy was valid during the period from 16 March, 2009 to 15 March, 2010. Dr. Sawant* had an eye surgery during this period and when she made a claim for reimbursement of the cost, the insurance company rejected it saying that she had only received injections for macular degeneration, which is not an eye surgery and therefore she was not eligible for reimbursement as per the policy terms.

On refusal from the insurance company, Dr Sawant* approached CERS and after verifying the details, CERS filed a complaint before the Consumer Dispute Redressal Forum, Ahmedabad (Additional). CERS also submitted that the administration of injection to Dr. Sawant* is done under local anaesthesia and is a surgical procedure related to Retina and Vitreous surgery. The procedure has to be carried out in an Operation theater. So, it is definitely a type of ‘EYE SURGERY’. And for ‘Eye Surgery’, hospitalisation of 24 hours or more is not necessary for reimbursement of claim as per the terms and conditions of the insurance policy. After hearing both the parties, the forum did not find any merit in the arguments made by the insurance company and accepting the certificate issued by the doctor, who performed the surgery, it ruled the order in favor of the complainant.

The forum has not only ordered the insurance company to reimburse the cost of eye surgery i.e. Rs. 72,029 but also to pay interest @8% on this amount from 22/1/2010 for denying the reimbursement. It has also ordered the insurer to pay Rs. 5,000 towards compensation for mental agony faced by the doctor and Rs. 3,000 towards the litigation cost.

However, the total claim amount was Rs. 1,44,058/- (cost of 2 injections of Rs. 72,029/- each). But through oversight, the Forum granted claim for only one injection. So, the complainant will have to file an Appeal before the State Commission to claim the full amount i.e. Rs. 1,44,058/-.

*Name changed on request

For further information please contact

Ms Pritee Shah (O) 079-27489945/46

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