Ombudsman asks insurance company to settle mediclaim

Ludhiana, October 21

Holding the denial of a mediclaim by the insurance company to be improper and unreasonable, the Insurance Ombudsman has directed the company to settle the claim within 30 days.

“The repudiation of the claim by the insurance company with the plea that the treatment didn’t require hospitalisation is based on erroneous reasoning since the decision for the particular mode of treatment is entirely based on the treating doctor’s recommendations which are further based on various other factors such as general condition, age of patient and other attending circumstances. The treatment by intravitreal injection is highly specialised treatment i.e. generally being done in operation,” observed the Ombudsman.

The Insurance Ombudsman passed the orders while deciding a complaint moved by Satish Kumar Malhotra of Kidwai Nagar, Ludhiana.

The complainant has submitted that he submitted claim with the United India Insurance Company for operation of his eyes, but the same was denied. He remained hospitalised for a day in July 2017.

However, the insurance company pleaded that the complainant was treated with intravitreal injection under local anesthesia which could have been done on OPD basis and does not require hospitalisation. So the claim was not payable.

But after hearing both the parties and appreciating the evidence on record, the Insurance Ombudsman disagreed with the decision of the insurance company. — OC