Case title: Johny Milton v Universal Sompo General Insurance Company Ltd.
Summary
The Kerala Consumer Commission has ordered an insurance company to reimburse the medical expenses incurred by a policyholder for the treatment of his mother, despite her not being hospitalized for 24 hours. The commission argued that the treatment should not be excluded from health insurance policies in accordance with IRDA guidelines. The insurance company labeled the Accelrix ocular injection as an “outpatient procedure,” but the Commission disagreed, stating that “Intra vitreal injections” should not be excluded from health insurance policies. The Commission ordered the insurer to reimburse the complainant for hospitalization expenses, pay Rs 20,000/- as compensation, and grant Rs. 10,000/- for litigation expenses.
About the case
A Consumer Commission in Kerala has ordered an insurance company to reimburse the medical expenses incurred by a policyholder for the treatment of his mother (included in the policy), despite the fact that she was not hospitalized for 24 hours. The commission noted that the treatment provided to her should not be excluded from health insurance policies in accordance with IRDA guidelines.
The procedure should be regarded as “day care treatment” by the Bench, which is composed of President D.B. Binu and Members Ramachandran V and Sreevidhia T.N. This classification encompasses medical procedures that would necessitate a hospitalization lasting more than 24 hours but were completed in less than 24 hours as a result of technological advancements.
The complainant’s mother was diagnosed with Myopic Choroidal Neovascular Membrane in her left eye and has requested reimbursement for the Rs. 27,720 expense she incurred as an “inpatient for a day care treatment.”
Accentrix ocular injection is labeled as a “outpatient procedure” by the Company.
The Commission disagreed, asserting that “Intra vitreal injections” should not be excluded from health insurance policies in accordance with the guidelines established by the Insurance Regulatory and Development Authority of India.
“The Complainant argues that the rejection is unfair and is based on false grounds.” The procedure is not prohibited by the policy terms and guidelines, and the patient was evacuated on the same day as a result of advanced technology and infrastructure. The Commission observed that the Opposite Party’s rejection of the claim based on this procedure is inconsistent with the IRDAI guidelines.
It also observed that the insurer was adopting an inconsistent stance on the matter, as it permitted a comparable procedure that was implemented later that year without objection.
“This inconsistency in the Opposite Party’s actions suggests an unfair trade practice,” the Commission stated in its order to the insurer to reimburse the Complainant for the hospitalization expenses and pay Rs 20,000/- as compensation for the deficiency of service, mental anguish, and physical distress. Additionally, it granted Rs. 10,000/- for litigation expenses.
