Claim amount for cataract op cannot be fixed: Court | Vadodara News


Vadodara: A uniform amount for cataract surgeries cannot be assumed or fixed by insurance companies while dealing with claims of insured persons, a court here ruled last week.
The Vadodara District Consumer Disputes Redressal Forum turned down the claim of Oriental Insurance Company Ltd and third-party administrator MD India Health Insurance TPA Pvt Ltd’s claim that Rs 24,000 is a reasonable amount for cataract surgery on one eye.
The forum was hearing a complaint filed by a resident of Harni Warasia Ring Road, Dr T J Prajapati, who had undergone cataract surgery for his left eye in November 2019. Prajapati incurred an expense of Rs 42,000 for the surgery, but the insurance company and the TPA paid just Rs 24,000.
Court stated that ophthalmologists use imported lenses and expensive materials to ensure that cataract surgery is done properly so that the patient’s eye and vision remain healthy. “In such circumstances, the operation expenses may be more. It all depends on which expert is doing the surgery and is using which type of lens and there is no condition in the policy that a specific type of lens can only be used,” the forum stated in the judgment.
During the hearing, the opponents’ lawyer submitted that the remaining amount of Rs 18,000 was deducted as per the cataract limit of the policy. It was argued that as per the policy of the insurance company Rs 24,000 can only be considered as reasonable and customary expense for cataract surgery and the expense of Rs 42,000 incurred by Prajapati is excessive.
Opposing the insurance company and TPA’s argument, Prajapati’s lawyer told the court that the money was deducted wrongly because Prajapati was never told under which clause of the policy it was done nor any such clause is stated in the policy which he had bought in 2010. The court’s attention was also drawn to the fact that the TPA had deducted the amount and the insurance company did not write any letter to Prajapati informing him that money has been deducted and under which clause.
The court upheld the arguments and also went on to note that the insurance company and TPA could not support its claim that Rs 24,000 is a reasonable amount by submitting any expert doctor’s opinion.



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Elena Johaness

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