CHENNAI: An insurance company was directed to pay the amount incurred for a dental surgery by a resident of the city. The consumer forum rejected the argument that the dental surgery falls under “cosmetic” category and directed the insurance company not just to pay for the surgery but also pay Rs 50,000 more as compensation for delaying the rightful reimbursement and causing ‘mental agony.’
The complainant, Surendra S Jain, was hospitalised at Dr Mehta Specialty Hospital in December, 2014 for an odontogenic keratocyst procedure. Jain had incurred a total expenditure of Rs 1,44,374 and had submitted the forms to MD India Healthcare Services (TPA). However, MD India repudiated the claim and said the procedure was excluded from the scope of the policy and hence the claim was not payable.
Despite Jain writing two letters, validated by a doctor’s certificate, that sought to explain that the procedure was not dental treatment but a disease, it had no effect. “Any dental treatment or surgery which is corrective, cosmetic or of aesthetic procedure, filling of cavity, root canal including wear and tear etc unless arising from disease or injury and which requires hospitalisation for treatment,” the policy reads.
Both the opposite parties, Oriental Insurance Company and MD India, claimed that they could not reimburse the amount as it was a violation of a clause in the policy document.
Therefore, the parties claimed that “the treatment was for external congenital disease or defect which is excluded from the scope of the policy and the complainant had undergone dental treatment without any hospitalisation without any disease or injury which is not covered by the policy.”
District Consumer Redressal Forum, Chennai (North), said that the opposite parties had not filed any proof that mandible cyst or odotongenic keratocyst is either a genetic disorder or a congenital disease.
“In the case in hand, the complainant was treated as inpatient for four days,” K Jayabalan, president of the forum, observed. “Therefore, the claim being repudiated quoting these exclusion clauses is not sustainable and consequently we hold that the opposite parties have committed deficiency in service in rejecting the claim made by the complainant.”
The forum directed payment of Rs 1,35,424 towards treatment, Rs 50,000 towards mental agony suffered by Jain and Rs 5,000 towards litigation charges.
Beauty and ailment
Surendra S Jain underwent odontogenic keratocyst procedure
Incurred expenditure of Rs1,44,374 and submitted claims for same
Claims rejected by company which classified procedure as ‘cosmetic’
Forum awards Rs 1,35,424 towards treatment, Rs 50,000 for mental agony and Rs 5,000 towards litigation charges