Consumer discussion board guidelines that medicine for the ailment will not be lined by plans primarily based on National Medicare Guidelines
The Additional Thane District Consumer Disputes Redressal Forum has dismissed a person’s plea seeking compensation from a non-public insurance coverage firm for a surgery to deal with erectile dysfunction. The discussion board dominated that medicine for the ailment will not be lined by plans primarily based on the National Medicare Guidelines.
The man obtained a rider coverage from March 2016 to March 2018, which elevated the sum assured, and a top-up coverage from November 2017 to November 2019 from ICICI Lombard General Insurance Company. On January 22, 2018, he wrote to the corporate seeking a pre-authorisation letter for a penile implant surgery.
Rejecting the request, the corporate mentioned, “Present ailment for which treatment is being availed is not covered; hence the cashless hospitalisation request is rejected.” He despatched a authorized discover to the corporate on February 1, 2018, however didn’t obtain a reply. He underwent the surgery on February 16, 2018.
The man then moved the discussion board seeking ₹6.24 lakh with 18% curiosity from March 2018, ₹2 lakh as compensation, and ₹30,000 for the psychological torture suffered.
The firm’s counsel in its reply denied deficiency in service and unfair commerce follow. The counsel mentioned the request was rejected because the ailment isn’t lined beneath its mediclaim coverage.
The Bench, comprising presiding member G.M. Kapse and member S.A. Petkar, mentioned the case relies on phrases and circumstances of the coverage, pre-authorisation letter, and medical certificates of the physician. The Bench mentioned, “Under the law, drugs to treat erectile dysfunction are excluded from the coverage unless they are used as a part of treatment approved by the Food and Drug Administration for a different situation.”
Dismissing the plea, the Bench mentioned, “When the insurance policy was purchased by the complainant, he was aware of all the terms and conditions of the policy, including exclusion of ailments. Hence, the complainant is not justified to claim any amount.”