21 March 2013
The Maharashtra State Consumer Disputes Redressal Commission has rejected an insurance company’s contention that a laser surgery to correct one’s vision is a cosmetic surgery. Upholding a district forum order that held The United India Insurance Company Ltd guilty for repudiating a claim on this ground, the commission directed it to pay an Andheri-based senior citizen the insured amount of Rs 50,000 with a compensation of Rs 1,000.
“There is no documentary evidence led by the appellant (insurance company) to demonstrate that lasik surgery (a form of laser surgery) is not a corrective therapy, especially when the complainant was experiencing serious problem in the eye,” the commission said. K P Desai (61) had regularly subscribed to the mediclaim policy issued by the insurance company from 1990 till 1997. During the validity period of the last mediclaim, he underwent a corrective lasik surgery in one eye and the hospital charges amounted to Rs 50,000. He filed aclaim for reimbursement of the hospital charges. However, the insurance company repudiated the claim on the grounds that the operation was purely cosmetic and aesthetic, and did not fall within the purview of the insurance policy. Laser eye operation not cosmetic: Forum
Aggrieved, Desai filed a complaint with the South Mumbai District Consumer Disputes Redressal forum in 1997. On April 19, 2004, the district forum ruled in Desai’s favour.
The insurance company then filed an appeal against the ruling. It said the district forum had erroneously held that the lasik therapy carried out on the complainant’s eyes was not one of the procedures excluded in the terms and conditions of the insurance policy. Lawyer Sureshchandra N Chataule represented Desai in the commission, which pointed out that under the provisions of mediclaim, hospitalization expenditure, including for surgery, is admissible after the completion of five years of continuous insurance coverage.
“We find that there is no statement by the insurance company as to how the exclusion clause of the mediclaim comes into operation while denying reimbursement of the expenses to the complainant after the completion of the fifth year,” the commission said, dismissing the appeal saying it did not find