Insurer made to pay for ‘non-medical’ deductions

Insurer made to pay for ‘non-medical’ deductions

 NimeshKhakhariya@timesofindia.com 27.09.2024 

 Rajkot : A consumer court of Rajkot rejected a deduction made by a health insurance company for reasonable, customary and non-medical item charges in the cataract treatment of a 45-yearold man and called it a deficiency in service. A Rajkot resident, Chirag Jasani, bought the Happy Family Floater policy health insurance from Oriental Insurance Company Ltd for the period of March 6, 2023, to March 4, 2024. Jasani had been a policyholder for 11 years and his sum assured was Rs 5 lakh. He had a vision problem and needed cataract treatment in both eyes as an indoor patient. His right eye was treated between July 10 and 11, 2023, for which he paid a medical bill of Rs 88,090. He underwent treatment for his left eye between July 24 and 25 and paid Rs 89,007. He spent Rs 1.77 lakh on both eyes. 

He filed a claim befobut the company sanctioned only Rs 48,000. Jasani moved the consumer court. The insurer submitted that they approved the partial claim after deducting the reasonable and customa ry charges, non-medical items and co-payment. The court order stated that Rs 500 deducted as nonmedical expense for the right eye and Rs 5,600 deducted as hospital discount for the left eye were reasonable according to the terms and conditions of the policy. According to the terms and conditions, 10% was deductible as co-payment. 

However, the court, in its order dated Aug 31, rejected the argument of the insurance company regarding the deduction under reasonable and customary charges, stating that the company failed to prove medically that the expense by the policyholder was excessive, and the policyholder was not eligible to get it under the policy conditions.