The New India Assurance Company (NIAC) recently rejected the mediclaim of a resident from Billimora town in Gujarat’s Navsari district, who opted for squint eye correction surgery. After the matter reached
the Valsad Consumer Disputes Redressal Commission (CDRC), the body took exception to the NIAC’s decision.
The CDRC ordered the NIAC to pay a sum of Rs 4.12 lakh to the person. The commission also mandated that the insurance pay Rs 3,000 in compensation for both physical and emotional harassment, as well as 8 per cent interest on the sum.
Insurance Company Labelled Surgery As Cosmetic Procedure
On March 24, 2024, the complainant purchased a Rs 10 lakh mediclaim policy valid for one year from the insurer’s Billimora office. In September 2024, his daughter had divergent squint surgery on her right eye at a Mumbai hospital. The insurance company denied the claim on October 1, 2024, citing a policy provision and labelling the surgery as a cosmetic procedure. On January 2, 2025, the parent appealed this ruling to the Valsad CDRC.
The insurance company contended throughout the hearing that the surgery was performed outside of the Billimora branch’s jurisdiction. Additionally, it stated that squint correction is not covered by the Mediclaim policy because it is considered a cosmetic procedure. The insurer insisted that the claim’s denial was lawful.
Complainant Wins Legal Battle
By presenting a thorough medical report, the complainant’s advocate refuted the insurer’s claim. According to the article, the procedure was medically required and intended to improve vision rather than beauty. Eight arguments were made in favour of the treatment, including the reduction of eye strain when reading or using computers, the reduction of headaches brought on by misaligned eyes, the improvement of balance, the avoidance of falls on stairs, and the improvement of hand-eye coordination. A month before the procedure, the patient began to squint continuously, according to the report. This demonstrated that the ailment was a medical problem that needed prompt treatment rather than a congenital disorder.
The Valsad CDRC dismissed the insurance company’s claims after examining the medical evidence. The panel ruled that when squint correction surgery is done to enhance vision and everyday functioning, it cannot be considered a cosmetic technique. In addition to providing relief to the complainant and establishing a clear precedent for insurance claims about vision, the court ordered the insurer to pay the entire claim sum of Rs 4.12 lakh plus 8 per cent interest.
