Vadodara Consumer Forum Orders Insurance Company to Pay Rs 37,910 for Medically Necessary Mole Removal
In a significant ruling, the Vadodara District Consumer Disputes Redressal Commission has directed Oriental Insurance Company Ltd to reimburse a mediclaim of Rs 37,910 to a policyholder, overturning the insurer's rejection on grounds that the procedure was cosmetic. The case highlights the critical distinction between cosmetic and medically necessary surgeries under insurance policies.
Policyholder's Medical Condition and Claim Rejection
Sandip Bharadwaj, a resident of New Sama Road in Vadodara, underwent surgery in May 2023 to remove a large mole located under his eye. According to the complaint filed, Bharadwaj developed a pigmented mass-like mole on his face, which he consulted a doctor about. The medical professional advised surgical removal, diagnosing the growth as pre-malignant with a potential risk of developing into cancer. Additionally, the mole was reportedly causing significant difficulty in vision, interfering with daily activities.
After the procedure at a hospital, Bharadwaj submitted a claim of Rs 37,910 to Oriental Insurance Company Ltd to cover the medical expenses. However, the insurer rejected the claim, asserting that the mole removal surgery was cosmetic in nature. The company argued that such procedures are not covered under the policy, except in specific cases involving burns, cancer, or other health hazards. They contended that the surgery was primarily undertaken to beautify Bharadwaj's face, rather than for medical reasons.
Consumer Forum's Ruling and Compensation
Challenging the rejection, Bharadwaj approached the Vadodara District Consumer Disputes Redressal Commission in September 2023. The commission thoroughly examined the case, noting that the treating doctor had provided clear medical documentation. The doctor stated that the mole was large, pre-malignant, posed a future cancer risk, and importantly, interfered with Bharadwaj's vision, making the surgery medically necessary.
The consumer forum held that the procedure was not cosmetic but essential for health reasons, based on the medical evidence presented. Consequently, the commission ordered Oriental Insurance Company Ltd to pay the full claim amount of Rs 37,910 to Bharadwaj. Additionally, the forum mandated the payment of 9% interest on the amount from the date of the claim rejection until actual payment. To address the hardship faced by the policyholder, the commission also awarded Rs 2,000 as compensation for mental harassment and Rs 1,000 towards litigation costs, emphasizing the insurer's obligation to honor valid medical claims.
This ruling serves as a reminder for insurance companies to carefully assess medical necessities and for consumers to understand their rights under policy terms, ensuring fair treatment in health-related disputes.
