Mumbai: The Oriental Insurance Company Ltd has been directed by the state consumer commission to pay ₹1.21 lakh as medical expenses with 12% interest to a Khar resident, whose claim was rejected and was given only ₹1,759 on the pretext of treatment “not approved by the Indian Medical Council”. The firm also contended that the treatment fell under the firm’s “exclusion clause.”
The policy
Kiran Jain had approached the South Mumbai District Consumer Disputes Redressal Commission with a complaint regarding claim for enhanced external counter pulsation (EECP) also known as coronary artery bypass graft (CABG).
Jain had taken a policy worth ₹4 lakh by paying ₹16,424.
In March 2015, he was admitted to Asian Heart Hospital for CABG and was told that it would cost ₹4 lakh. He then approached IPC Heart Care Centre in Parel, which had a treatment plan for EECP instead of just CABG, requiring 45 sittings for ₹1.20 lakh.
Claim gets rejected
When he sent the insurance firm the bill, it cleared only ₹1,759 as full and final settlement. While rejecting the claim, the company said that the treatment fell outside the purview of its policy and that EECP is not medically approved by the Indian Medical Council as it’s experimental.
During the hearing, the commission observed that the firm “has not produced a single documentary evidence to substantiate their contentions nor specifically mentioned relevant clause number for exclusion”.
Stating that there was deficiency in service, it asked that the money be paid to the complainant within 45 days of the order. The commission also gave ₹25,000 towards mental agony and litigation costs.
