Consumer Forum Orders Oriental To Pay Mediclaim Money

The Consumer Disputes Redressal Forum (CDRF), Ahmedabad has upheld the Consumer Education and Research Society (CERS) claim that Oriental Insurance Company Ltd should reimburse its member Dr Rohitkumar R Shah, medical expenses he incurred for undergoing surgery for an ear ailment under the Mediclaim policy.

Oriental Insurance had declined to pay for the surgery under the policy saying that Dr Shah's ailment was "pre-existing" and therefore he was not entitled to reimbursement.

It referred to the findings of its panel doctor, Dr Pravin N Patel, who averred that based on x-ray and other case papers Dr Shah's disease had existed since childhood.

 

The insurance company in support of its stand further stated that Dr Shah had renewed the Mediclaim policy after a gap of 13 months and, within two months of the renewal, had undergone the operation.

In his rejoinder, Dr Shah said he had undergone the operation for discharge in his right ear and that he had suffered the ailment for two months and not from childhood. He produced a certificate in this regard from Dr Mahendra Naik, a city ENT surgeon.

He also said that it was a "misconceived idea" to diagnose ear diseases by mastoid x-ray, which the insurance doctor had done.

CDRF while rejecting the insurance company's charge of pre-existing disease, came down heavily on Dr Patel, the panel doctor, saying that he had "failed to discharge his legal and moral duty" and had "simply" given his opinion from the file given by the insurance company."

It held that the repudiation of the claims of the medical policy-holder by Oriental Insurance Company was "illegal, void and without application of mind" and ordered payment of Rs 8,738 with 12 per cent interest and Rs 3,000 compensation for causing mental agony and harassment to Dr Shah. It also awarded Rs 1,000 as cost.