Consumer Court Orders Insurance Payout for Squint Surgery, Rejects Cosmetic Label
The Valsad Consumer Disputes Redressal Commission has delivered a significant verdict. It ruled that squint eye correction surgery qualifies as a vision correction procedure. The court firmly stated this is not a cosmetic treatment. This decision came in a case from Billimora town in Navsari district.
Court Directs Full Compensation with Interest
The commission directed The New India Assurance Company to pay compensation of Rs 4.12 lakh to the complainant. It described the insurance company's rejection of the mediclaim as completely unreasonable. The ruling emphasized the surgery was medically necessary to improve vision. It was not performed for aesthetic purposes.
In addition to the principal claim amount, the insurer must pay 8% interest. The court also ordered a payment of Rs 3,000 specifically for mental and physical harassment caused to the policyholder.
Policy Purchase and Claim Rejection Timeline
The complainant purchased a mediclaim policy from the company's Billimora branch. This happened on March 24, 2024. The sum assured was Rs 10 lakh, and the policy was valid for one year.
During the policy period, his daughter underwent right eye divergent squint surgery. The procedure took place at a hospital in Mumbai in September 2024. The insurance company rejected the claim on October 1, 2024. They labeled the surgery as cosmetic and cited a specific policy clause.
The parent challenged this decision at the Valsad CDRC on January 2, 2025.
Arguments Presented During the Hearing
During the court hearing, the insurance company presented two main arguments. First, they contended the surgery was performed outside the branch's jurisdiction. Second, they insisted squint correction falls under a cosmetic classification. The company argued their claim denial was legally valid based on these points.
The complainant's advocate provided a strong counter-argument. He stated the surgery was functional and medically necessary. This position was supported by a detailed doctor's report submitted as evidence.
Doctor's Report Details Medical Necessity
The medical report listed eight specific reasons why the procedure was essential for the patient's eyesight. These reasons provided clear functional benefits:
- Reducing eye strain while reading or using computers.
- Reducing headaches caused by eye misalignment.
- Improving balance and preventing falls, especially on stairs.
- Enhancing hand-eye coordination for daily activities.
The report also contained a crucial medical observation. It noted the patient developed a continuous squint just one month prior to the surgery. This confirmed the condition was not congenital. It was a medical issue that required timely correction.
Court's Final Ruling and Order
The consumer commission accepted the doctor's detailed report as compelling evidence. It rejected all contentions raised by the insurance company. The court directed the insurer to make full payment of Rs 4.12 lakh. This payment must include 8% interest from the date of the claim rejection. The ruling sets a precedent for similar mediclaim disputes involving functional eye surgeries.
