Firm to pay over Rs 1L for rejecting mediclaim

Observing that insurance firms are repudiating claims on one pretext or the other in many cases, a consumer forum here has asked an insurance company to pay over Rs one lakh to a man whose son's medical claim was deficiently rejected by it
Central Delhi Consumer Disputes Redressal Forum, presided by Rakesh Kapoor, asked the New India Insurance Company to pay the money to Delhi resident Rajan Malhotra.
"...It has been noticed that in a number of cases, the insurance companies are repudiating the claims lodged by the insured on one pretext or the other. The courts/fora have impressed upon the officers/ officials of the insurance company to act in a manner which advances the purpose of the insurance contract," the forum, also comprising its member S N Shukla, said.

In this case, the insurance firm had rejected the medical claim for Implantable Contact Lens (ICL) treatment in the eyes of the complainant's son through an operation, while holding that it was a 'cosmetic surgery' and was not covered under the policy.
The forum noted that company did not dispute that ICL implantation is a recognised medical procedure and is being undertaken in a number of cases and for a number of years now.
"Since, it is a recognised medical procedure by no stretch of imagination it can be termed as a cosmetic surgery.... We are inclined to hold that the repudiation of the claim was unjustified and uncalled-for," the forum said.

Malhotra told the forum that he was holding a mediclaim policy of the insurance company. In 2011, his son was diagnosed as a case of pathological myopia and was advised ICL implantation.

An operation was carried out and the complainant sought a claim of Rs 1,11,000. However, it was repudiated by the firm.
Aggrieved by this, Malhotra approached the forum for redressal of his grievance alleging deficiency in service by company.
The company, however, told the forum that the eye surgery undergone by Malhotra's son was found to be a 'cosmetic surgery' and it was not covered under the policy. Hence the firm was not liable to pay the claim.