Insurance company cannot decide which lens to insert in cataract surgery, is obliged to pay compensation Insurance companies cannot decide which lens to insert in cataract surgery, but are obliged to reimburse

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A reputed orthopedic surgeon of the city had shown imported lenses in both eyes to avoid difficulty in surgery. Under the medical claim policy of 5 lakhs, he claimed to get compensation of 1.40 lakhs for surgery of both lenses. The insurance company approved 58,000 claims through both lenses. Against which the doctor complained in the Consumer Protection Commission and ordered to pay the amount of 82 thousand with 8 percent interest. Preeti Shah, a member of the Consumer Commission, observed that the insurance company cannot decide the quality of lenses to be fitted by the complainant.

1.40 lakhs claim for lens surgery
Dr. Rikesh Mazmudar complained before the State Consumer Commission that he had taken a medical claim policy from a private insurance company in the year 2015-16. After 6 months, cataract surgery was done in both his eyes. As the complainant himself is a surgeon, he chose high quality lenses for the surgery. The cost of the lenses he inserted in both eyes was 1 lakh 40 thousand. He filed a claim with the insurance company and the company approved the claim of 58 thousand rupees. An amount of 82 thousand was deducted without giving any reasonable reason. The plaintiff doctor argued that he was an orthopedic surgeon by profession and needed a clearer vision of the eye to perform the surgery. So he preferred good quality lenses during cataract surgery. But the insurance company deducted the compensation on the grounds that the complainant had fitted multi-focal cosmetic lenses which were unnecessarily expensive. The Consumer Commission rejected the contention of the insurance company and ordered to pay the outstanding compensation of 82 thousand.

The insurance company should clarify the terms
In its judgment, the Consumer Commission observed that if there is no clarity in the conditions that the insurance company has placed while issuing the policy, the insurance company has to pay the full amount of compensation. In the present case, the doctor had presented all the terms of the policy before the commission without any clarification as to the type of lens to be inserted. The insurance company cannot decide which lenses the customer should wear. By reading and signing all the terms and conditions before taking any medical claim policy, one can claim full amount.