Ahmedabad : Nearly eight years after a health insurance claim was rejected, the District Consumer Disputes Redressal Commission (Additional), Ahmedabad, has directed The Oriental Insurance Company Ltd to pay Rs 1,05,224 with 7% annual interest to a city resident who underwent treatment for a spinal condition.
The complainant, Mahmandyasin Ismail Hokabaj, had approached the consumer commission through the Consumer Education and Research Centre (CERC) after his insurer declined to reimburse medical expenses incurred during treatment in Aug 2016. Hokabaj had purchased a family floater policy with a sum insured of Rs 2 lakh for the period from Oct 1, 2015 to Sep 30, 2016, according to the case record. He was admitted to Stavyah Spine Hospital on Aug 28, 2016, for treatment of ossification of ligamentum flavum at D9, D10, D11 and D12, incurring medical expenses of Rs 1.16 lakh. The insurer rejected the claim citing Clause 4.3 of the policy, which prescribed a two-year waiting period for certain treatments, including surgery for a prolapsed intervertebral disc unless caused by an accident. the commission applied the policy’s 10% co-payment condition and reduced the payable amount to Rs 1,05,224 While determining compensation.
However, the consumer commission observed that Hokabaj’s treatment was for ossification of the ligamentum flavum and not for a prolapsed intervertebral disc. It held that the exclusion clause relied upon by the insurer was not applicable in the case.