Dr. Diksha Sawant, a resident of Ahmedabad, filed a complaint with Consumer Education and Research Society (CERS) regarding denial of claim by The Oriental Insurance Company for her eye surgery. On hearing both the parties and on merits passed an order directing the company to reimburse Rs. 72,029 towards cost of surgery along with 8% interest on delayed payment, Rs. 5,000 as damages for mental torture suffered by her and Rs. 3,000 towards legal action charges.
The fact of the case is that Dr. Diksha Sawant had purchased a health insurance policy from The Oriental Insurance Company in 1993 and has been paying premium on a regular basis since then. During the tenure of the policy she had undergone an eye surgery and when approached the company for reimbursement of claim, she was denied the claim based on the ground that she had only received injection for macular degeneration which is not an eye operation and hence claim cannot be honored.
Aggrieved by the order of the insurance company, she approached CERS, who after studying the facts filed a complaint with Consumer Dispute Redressal Forum, Ahmedabad. CERS also put forward that injection to doctor is given under local anesthesia and is a surgical procedure connected to retina and vitreous surgery, which has to be carried out in operation theatre.
On hearing both the parties, Consumer Dispute Redressal Forum, based on the contention put by CERS and certificate issued by the doctor who performed the surgery and on merit of the case, passed an order in favor of the doctor and awarded compensation as stated above.
