Hyderabad: Oriental Insurance fined Rs 67,500 for denying complete coverage for cataract surgery

Hyderabad: The Oriental Insurance Company Ltd has been ordered to pay Rs 10,000 as compensation to the complainant for the mental agony and harassment caused at his advanced age due to the deficiency in service.

The District Consumer Redressal Commission-II here also directed to pay the remaining amount of Rs 67,500 towards the expenses incurred for the surgery to the complainant as per the PPN Tariff, along with interest at the rate of 9 per cent per annum from the date of claim settlement i.e., from April 25 till the realisation.

Case details

Vinay Asar is a resident of Jubilee Hills, Hyderabad. He had a Happy Family Floater Health Insurance policy issued by Oriental Insurance Company Ltd. For renewal of the same, the complainant paid Rs 97,545 on August 28, 2023.

The policy was renewed from September 1, 2023, to August 31, 2024.

After a few months, on March 8, 2024, Vinay visited the Swarup Eye Centre at Dwarakapuri Colony, Punjagutta for a checkup. The doctors recommended cataract surgery on the right eye.

Vinay received an estimated cost of Rs 89,500 from Swarup Eye Centre for the surgery. The estimate was sent via WhatsApp by the complainant’s insurance agent to the opposite party and was acknowledged by them. On March 8, his right eye cataract (Z8 FEMTO + PHACO-PC IOL) was done at the Swarup Eye Centre.

Vinay paid Rs 89,500 for the surgery including the cost of the lens implant and other related expenses including operation theatre charges, surgeon charges, anesthesiologist charges, etc. The claim form, along with Swarup Eye Centre’s bill and other requisite documents, was submitted to the opposite party through his insurance agent.

Oriental paid only Rs 22,000

The same was acknowledged by the Oriental Insurance Company Ltd via email on March 29. The opposite party sent an email on April 25, advising that only an amount of Rs 22,000 would be paid against the claim of Rs 89,500. This amount was subsequently transferred to the complainant’s account on April 30.

In the mail, the company said ‘Procedures: Rs 50,000 not payable ZB FEMTO charges’ and various amounts were not payable as they exceeded the GIPSA package. At the time of issuance of policy and renewal of the policy, there was no mention of any GIPSA package.

Despite paying the full premium as demanded by the opposite party at the time of renewal of the insurance policy, and despite submitting all the requisite documents supporting the complainant’s claim, the opposite party settled the claim for only Rs 22,000 instead of the claimed amount of Rs 89,500.

As Oriental Insurance Company Ltd raised no objections after being made aware of the surgery estimate, Vinay assumed the opposite party would reimburse the entire amount upon submission of the relevant bills. Not satisfied with the partial reimbursement of Rs 22,000 he emailed the grievance cell on April 26 but received no response.

The failure to pay the actual claim amount by Oriental Insurance amounts to a deficiency in service and unfair trade practice. The opposite party filed its version, denying all the allegations against them and contending that there was no deficiency of service on their part since the complainant’s claims were settled in accordance with the terms and conditions of the policy and applicable norms.

No mention of OT charges and implants

While settling the claim, the opposite party confirmed that they had communicated the reasons for disallowing the balance amount via email, and the complainant acknowledged receipt of this communication. After hearing the arguments from both parties, the court observed that there is no mention of OT charges and implants separately.

However, Oriental Insurance has selectively separated charges for the surgery packages ‘MICS’ and ‘FEMTO CATARACT’ which were listed at Rs 39,500 and Rs 50,000 respectively. When the package rates are listed for specific surgeries, denying these packages and separating OT and other charges without further clarification on applicable coverage or reimbursement terms demonstrates negligence.

The court ruled in favour of Vinay and directed the Oriental Insurance Company Ltd to pay Rs 5,000 towards the costs of the litigation.