Vadodara Consumer Forum Delivers Landmark Ruling on Insurance Claim Dispute
In a significant decision that clarifies insurance coverage for modern medical procedures, the Vadodara District Consumer Disputes Redressal Commission has ruled in favor of a patient whose insurance claim was rejected by The Oriental Insurance Company Ltd. The forum's judgment establishes that treatment administered after anaesthesia qualifies as day care treatment, entitling patients to insurance benefits even without 24-hour hospitalization.
The Case Background: A Denied Insurance Claim
The dispute originated when Manjalpur resident Jaiswal, who had maintained an insurance policy with The Oriental Insurance Company since 2018, underwent silicone oil removal surgery in his right eye at a private hospital in 2023. Despite being discharged on the same day, Jaiswal filed an insurance claim of Rs 36,258 for the surgical expenses.
The insurance company rejected his claim, arguing that since Jaiswal was not admitted to the hospital for more than 24 hours, the procedure did not qualify as day care treatment under their policy terms. The company maintained that this constituted an outpatient department (OPD) case, which was not covered under their day care treatment provisions.
Legal Proceedings and Arguments
Frustrated by the rejection, Jaiswal approached the Vadodara consumer forum in July 2024. Represented by advocate Ganesh Khopde, the complainant challenged the insurance company's interpretation of day care treatment.
"The insurance company insisted that Jaiswal was not admitted for more than 24 hours and therefore it was not a case of day care treatment," explained Khopde. "They claimed it was merely an OPD case, despite the surgical nature of the procedure."
The Forum's Groundbreaking Observation
The consumer forum carefully examined the evolving nature of medical treatment in its ruling. The panel observed that advances in medical science have significantly accelerated recovery times for many procedures. In contemporary surgical practices, patients are often administered anaesthesia in operating theatres, treated, and discharged on the same day to minimize infection risks and hospital stays.
"It is a surgical process in which one does not have to be hospitalised for 24 hours," the forum noted. "But the treatment is done after administering anaesthesia and hence it is included in day care treatment. The insured person has the right to get his claim amount for the treatment expenses."
The forum emphasized that the insurance company had wrongfully rejected Jaiswal's legitimate claim by applying outdated criteria that don't reflect modern medical realities.
The Final Verdict and Compensation
In its comprehensive ruling, the Vadodara consumer forum directed The Oriental Insurance Company to:
- Pay Jaiswal the full claim amount of Rs 36,258
- Add 8% interest on this amount from the date of claim rejection
- Complete payment within two months of the order
Additionally, recognizing the distress caused to the complainant, the forum ordered the insurance company to pay:
- Rs 2,000 as compensation for mental harassment
- Rs 1,000 toward litigation costs
"The forum allowed the claim stating that though the patient was not admitted for 24 hours as modern technology enables faster treatment, it was still a day care case," added advocate Khopde. "Hence the insurance firm should pay the claim amount."
Broader Implications for Insurance Policyholders
This ruling establishes an important precedent for insurance consumers across India. By recognizing that treatment under anaesthesia constitutes day care treatment regardless of hospitalization duration, the forum has aligned insurance practices with contemporary medical advancements.
The decision highlights how insurance companies must adapt their policies to reflect changing medical practices rather than relying on rigid, outdated criteria. For policyholders, this judgment reinforces their rights to legitimate claims for modern medical procedures that prioritize faster recovery and shorter hospital stays.
