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biotech/news//Hindustan Times
Seema Goyal had approached the consumer panel after the insurance company partially rejected her medical claim arising from treatment at Fortis Hospital, Mohali.
The commission ruled that 'atypical hyperplasia' is a precancerous condition covered by the policy.
KEY POINTS
The insurer must pay Seema Goyal ₹43,090 plus 9% interest from April 3, 2025.
New India Assurance was also ordered to pay ₹20,000 for mental agony and litigation expenses.
Robotic surgery for precancerous conditions like atypical hyperplasia may be covered despite policy restrictions.
The commission, comprising president S.K. Aggarwal and members Paramjeet Kaur and Lt Col Jasbir Singh Bath, ordered the insurer to pay ₹43 K along with interest and compensation to complainant Seema Goyal, a resident of Sector 68, Mohali.
Goyal had approached the consumer panel after the insurance company partially rejected her medical claim arising from treatment at Fortis Hospital, Mohali, in October 2024.
The hospital raised a bill of ₹2.12 lakh for the treatment. The insurer approved ₹65,000 towards surgery charges and later paid only ₹15,972 for medical investigations, pharmacy and related expenses. The complainant alleged that she paid the remaining amount from her own pocket and sought reimbursement of ₹43,090, which she claimed was still pending.
In its reply, the insurance company stated that robotic surgery expenses were admissible only for malignant cancer, brain, heart and spine-related ailments under the policy terms and conditions. Since the complainant was not diagnosed with cancer, the insurer argued that the deduction was justified.
After examining the medical records, the commission observed that the complainant had been diagnosed with “Atypical hyperplasia on endometrial biopsy”. The order noted that the condition has a significant connection with cancer and is considered a precancerous condition with a risk of progressing to endometrial cancer.
The commission held that the condition was covered under Clause D(9) of the policy and observed that there was no justification for deducting the disputed amount from the claim.
The bench directed New India Assurance to pay ₹43,090 with 9% annual interest from April 3, 2025, within 30 days. The insurer was also directed to pay ₹20,000 towards mental agony, harassment and litigation expenses.