In a landmark decision that highlights the power of consumer rights, a district consumer forum in Rajkot has ordered an insurance company to honour a medical claim it had previously rejected. The case involved a policyholder who had faithfully paid her premiums for over two decades, only to have her first-ever claim denied.
23 Years of Premiums, One Rejected Claim
The complainant, Nisha Rathod, aged 54, had held a medical insurance policy with The Oriental Insurance Company Ltd since the financial year 2023-24. Her policy came with an assured sum of Rs 5 lakh. For 23 years, she paid her premiums without filing a single claim.
Her first claim arose when she suffered from severe knee pain. Between July 24 and 28, 2023, she underwent a procedure known as high tibial osteotomy on her right knee at a hospital in Ahmedabad to treat osteoarthritis. Following the treatment, she submitted a claim for Rs 3.90 lakh with all necessary supporting documents.
The Insurer's 'Experimental Treatment' Defence
The insurance company, however, flatly rejected her claim. In its rejection, the insurer stated that the patient was treated for osteoarthritis with "resto knee surgery," which it classified as an "experimental or unproven treatment." The company argued this therapy was "not based on established medical practice in India" and was therefore not covered under the policy terms.
This decision left Rathod, a long-term customer, shocked and aggrieved. She decided to challenge the insurer's stance by approaching the Rajkot District Consumer Disputes Redressal Commission.
Consumer Court Upholds Patient's Right to Treatment
Rathod's legal representative, advocate Shailendra Jadeja, presented a compelling argument before the forum. "We argued that it is not the right of insurance companies to decide what kind of treatment a patient should get," Jadeja stated. "The doctor decides the best treatment for the patient, which gives protection against future risk."
The consumer court carefully examined the arguments from both sides. In its order, the bench noted a critical failing in the insurance company's case: it could not provide any solid evidence or base to prove that the treatment Rathod underwent was indeed experimental or unproven. The court found no reason to disbelieve the complainant's version of events.
The Final Verdict and Compensation
In a decisive order dated November 17, the consumer forum directed The Oriental Insurance Company Ltd to pay Rathod the claimed amount of Rs 3.90 lakh. Furthermore, the company must pay 6% annual interest on this sum from July 25, 2024. The entire payment must be completed within two months of the order's issuance.
Adding to the insurer's liability, the court also ordered it to pay Rs 5,000 to cover Rathod's legal expenses incurred during the proceedings. This ruling serves as a significant reminder that insurance companies must have substantial, documented grounds to deny claims, especially those from long-standing policyholders.
The case underscores the vital role of consumer forums in protecting policyholders from arbitrary claim rejections and reinforces the principle that the choice of medical treatment ultimately rests with the attending doctor and the patient, not the insurance provider.
