Mediclaim – Rejection on ground of minimum 24 hour hospitalization

Mediclaim – Rejection on Ground of Minimum 24 hour Hospitalization

Cataract Surgery and several other eye surgeries are conducted in operation theaters, but are over in a few hours.
Hospitalization is actually not required.

Insurance companies routinely reject claims relating to these surgeries on the wrong assumption that minimum 24 hour hospitalization is required.

In a recent decision, the District Forum of South Mumbai has held that such claims have to be paid.

They have observed:

“We upon considering the said policy condition find that the contention raised by the Opposite Party that the claims made by the Complainant to the Opposite Party are not payable as per clause no.2.3 is totally improper. In our view in the said clause it is specifically mentioned that the limit of 24 hrs hospitalization is not applied to  specific treatments and to the eye surgery in case of stay in hospital of less than 24 hrs. provided…….

“The Opposite Party is directed to discontinue the unfair trade practice of refusing to settle claims that may be lodged in future by the Complainant No.2 for the ailment viz; Macular Oedema and the same treatment viz; Ozurdex implant subject to overall sum insured being available under the policy. “

I am giving below the link to the full decision:

 file:///C:/Users/Eleena/Downloads/judgement2015-12-08.pdf