Hyderabad Ombudsman Centre
Case No. G-030/2006-07
Sri Dinesh Kumar Jain
Vs
Oriental Insurance Co. Ltd.
The complainant was covered under the individual Mediclaim policy for the period 21.07.2005 to 20.0.2006. He was admitted to eye hospital on 09.01.2006 and underwent Zyoptix surgery for both eyes. The insurer rejected the claim as the treatment fell under exclusion 4.5 of ht policy. The complainant contended that the operation was needed, as he was intolerant to contact lenses. The insurers contended that the power of the lenses worn by the hospital produced by the insured do not refer to any abnormal increase in Refractive Error.
Held: This office obtained an independent opinion from an expert eye doctor. This doctor opined that the surgery undergone would fall under cosmetic or aesthetic treatment. In view of the evidence of the doctor and the independent opinion, the decision of the insurer is upheld. The complaint is dismissed.
