KOCHI: In a judgment that could set a precedent, the Ernakulam District Consumer Redressal Commission has ordered an insurance company to pay compensation after it rejected a claim stating that the patient was at the hospital for less than 24 hours.
The commission’s ruling came following a complaint filed by Maradu native John Milton who submitted an insurance claim for his mother’s eye surgery, which was denied by Universal Sompo General Insurance.
Universal Sompo General Insurance is a joint venture between Sompo Japan Nipponkoa Insurance Inc, Dabur Investment Corp, Karnataka Bank Ltd, Indian Overseas Bank and Allahabad Bank.
The commission ordered the insurance company to pay a total of Rs 57,720 within 30 days. The company should reimburse Rs 27,720 towards hospitalisation expenses, while Rs 20,000 should be paid for “deficiency of service, and mental agony and physical hardships caused through the insurer’s action”, said the order. Another Rs 10,000 is towards the cost of the proceedings. “In light of the deficiencies in service and unfair trade practices observed, the commission finds merit in the complainant’s claims. The complainant is entitled to relief,” the order said.
John Milton’s mother underwent surgery for myopia at an eye hospital in Kochi recently. However, when he filed bills to claim hospital and medical expenses, it was rejected by the insurance firm on the ground that the patient had spent only less than 24 hours for the surgery procedure and hospital stay. This prompted John to approach the District Consumer Redressal Commission.
‘Insurance firm had okayed claim in similar case before’
The commission -- chaired by D B Binu and comprising Vaikom Ramachandran and T N Sreevidya as members -- found that the same insurance company had sanctioned a claim in a similar case before. The circular of Insurance Regulatory and Development Authority of India (IRDA) clarified that an injection used for myopia surgery is covered under medical insurance. The forum observed that as new technologies, including robotic surgery, are adopted in the medical field, insurance cannot be denied claiming that a patient was admitted to the hospital only for less than 24 hours.