Gujarat: the insurance company cites alcohol to deny the 7-year cataract claim

VADODARA: Insurance companies and third-party administrators invent countless ways to deny claims! But the reason cited by the State Health Insurance of India and MD to reject a health claim also did not impress the consumer court.

The company and TPA rejected the cost of eye treatment for a seven-year-old girl who said she had developed the condition due to the use of intoxicating material such as drugs or alcohol. They even cited obesity as one of the reasons for the development of the girl Manjalpur waterfall so his father spent Rs 62,388.

The girl Hetankshi had undergone treatment for removal of waterfall from her both eyes in July and October 2016 at Baroda Children Eye Care and Squint Clinic. But the insurance company and TPA rejected the claim sighting conditions of the mediclaim policy. According to the condition, treatment of ailments caused due to use of intoxicating material like drug or alcohol, obesity or intentional self-injury are not covered in the policy.

The girl's father, Gopal Devpura, filed a case against the insurance company and TPA at the Consumer Dispute Repair Forum of the Vadodara District to request reimbursement of the medical cost.

The patient was a seven-year-old girl and comes from a decent family, so the argument for rejecting the claim that she had used intoxicating material seems like a lot of fun, said Devpura's advocate, Heena Shrivastava.

The insurance company was also unable to present any document to support its arguments, something the court took into account, said Shrivastava.

The forum presided by G N Rana upheld the arguments that the waterfall was not developed due to alcohol, drugs or obesity . The court also observed that the insurance company had misinterpreted the condition of the policy to not pay the money.

He asked the companies to reimburse Rs 62,236 as treatment cost along with 8% interest and compensation of Rs 3,500.