Rajkot: The Rajkot District Consumer Disputes Redressal Commission has ordered The Oriental Insurance Company Ltd. to pay Rs 3.69 lakh to a resident after the insurer arbitrarily rejected the majority of his medical claim for cataract surgeries.The case was brought forward by Harsukh Suvagiya, a resident of Shastri Nagar, Rajkot, who held a medical insurance policy with a sum insured of Rs 8 lakh. Between May and July 2024, Suvagiya underwent Femto Second Cataract Surgery with PCIOL on both eyes, incurring a total medical expense of Rs 5.53 lakh.Despite having continuous coverage, the insurance company’s third-party administrator approved only Rs 80,000. It deducted a massive chunk of the claim, citing an “excess of defined or ailment limit”. Suvagiya then filed a formal complaint with the consumer commission.During the hearings, it was revealed that Suvagiya had been continuously renewing his policy since Oct 6, 2010, a period spanning over 13 years and 8 months. The commission strongly emphasised the “moratorium period” clause, noting that according to health insurance guidelines, once a policy has been continuously held for 8 years, a claim cannot be contested by the insurer on any grounds other than proven fraud or permanent exclusion.“The commission observed that the insurance company failed to produce any initial policy documents or evidence to justify their severe deductions under the ‘Ailment Limit’. The forum reiterated that the burden of proving that medical expenses are unnecessarily high or unreasonable lies entirely with the insurance company — a burden they failed to meet in this case,” said advocate S R Jadeja, representing Suvagiya in the court.While the commission allowed minor deductions for missing bills and miscellaneous unpayable expenses, it ruled that the remaining deduction was a clear deficiency in service.Delivering the final verdict on June 5, the commission ordered the company to pay the rightful claim amount of Rs 3.69 lakh with 6% annual interest from the date the complaint was filed.Furthermore, the consumer court issued a strict two-month deadline for the payment. If the insurance company fails to clear the dues within this timeframe, the interest rate will be hiked to 9%. The insurer was also directed to pay an additional Rs 5,000 to the complainant to cover his legal expenses.
