3 weeks ago
Mumbai Consumer Commission Pulls Up New India Assurance, Orders Payment
An insurance company called New India Assurance sold a family health insurance plan to a customer back in 2004.
The customer paid the premiums every year to keep the coverage active.
In 2012, the company added a new rule that limited how much it would pay for cataract eye surgeries, but it did not tell the customer about the change.
In 2014, the customer's father had cataract surgery on both eyes.
The medical bills were more than 81,000 rupees, but the insurance company paid only 48,000 rupees.
A consumer court in Mumbai said this was unfair because the company never informed the customer about the new limit.
The court ordered the company to pay back the remaining 33,642 rupees, plus interest, because the claim was not paid on time.
The court also said the company and its claims administrator had to pay compensation for the worry and trouble they caused.
The main lesson is that insurance companies must clearly tell their customers about any changes to their policies.
The District Consumer Disputes Redressal Commission, Mumbai Suburban, held New India Assurance and its TPA MD India Healthcare Services (TPA) Pvt. Ltd. guilty of deficiency in service and unfair trade practice.
A policyholder with a family Mediclaim policy continuously renewed since 2004 was not informed about a 2012 clause capping cataract claims at Rs 24,000 per eye.
Cataract surgeries on both eyes in June and July 2014 led to claims of Rs 41,642 and Rs 40,000, against which only Rs 24,000 per eye was paid.
The commission ordered New India Assurance to pay the Rs 33,642 balance with 9 per cent annual interest from April 1, 2015.
The insurer and TPA were jointly and severally directed to pay Rs 10,000 compensation for mental agony and Rs 5,000 litigation costs.
The commission rejected the two-year waiting period defence because the policyholder had maintained continuous coverage since 2004.
- Who
- The District Consumer Disputes Redressal Commission, Mumbai Suburban, found The New India Assurance Company Ltd. and its TPA, MD India Healthcare Services (TPA) Pvt. Ltd., deficient in service; the complaint was filed by the Consumers Welfare Association on behalf of a policyholder.
- What
- The insurer and TPA were held guilty of deficiency in service and unfair trade practice for applying an undisclosed Rs 24,000-per-eye cap on cataract claims and were ordered to pay the balance amount with interest.
- Where
- Mumbai, India, before the Mumbai Suburban consumer commission.
- When
- The order was reported on August 11, 2026; the surgeries took place in June and July 2014, and interest runs from April 1, 2015.
- Why
- Because the insurer introduced the cataract claim restriction without informing the policyholder, whose policy had been continuously renewed since 2004, and failed to prove the revised terms were brought to her notice.
Consumer Side
Insurer Side
Undisclosed claim cap
Consumer Side
The 2012 cap limiting cataract claims to Rs 24,000 per eye was introduced without the policyholder's informed consent, and the insurer produced no document showing she was told about it.
Insurer Side
The insurer paid only Rs 24,000 per eye, relying on the newly introduced clause in the revised 2012 policy.
Applicability of waiting period
Consumer Side
A two-year waiting period for cataract treatment cannot apply because the policy had been continuously renewed and coverage maintained since 2004.
Insurer Side
The insurer contended that a two-year waiting period condition for cataract treatment applied to the claim.
Full and final settlement
Consumer Side
Accepting the amount already paid did not mean the policyholder gave up the right to claim the balance.
Insurer Side
The insurer argued that acceptance of the amount already paid constituted a full and final settlement of the claim.
Key facts
- Commission
- District Consumer Disputes Redressal Commission, Mumbai Suburban
- Insurer
- The New India Assurance Company Ltd.
- TPA
- MD India Healthcare Services (TPA) Pvt. Ltd.
- Complainant
- Consumers Welfare Association on behalf of a policyholder
- Cataract cap
- Rs 24,000 per eye, introduced in the 2012 policy
- Claims
- Rs 41,642 and Rs 40,000 for surgeries in June and July 2014; Rs 48,000 paid
- Balance ordered
- Rs 33,642 with 9 per cent annual interest from April 1, 2015
- Additional relief
- Rs 10,000 compensation for mental agony and Rs 5,000 litigation costs
Quotes
Commission order
Decision statement by Mumbai Suburban Consumer Disputes Redressal Commission
“The complainant has suffered mental agony and harassment due to the non-payment of the balance claim by the insurance firm. The complainant has, therefore, made out a case of deficiency in service and unfair trade practice on the part of the insurer and is entitled to compensation.”
freepressjournal.in
Sources
Related news
Insurer must restore policy, pay Rs 1.10 lakh over hypertension
Manipal Cigna ordered to pay denied brain tumour surgery claim
Insurer to pay widow Rs 50 lakh after rejecting claim
Himachal Commission Upholds Insurance Payout After Hypertension Dispute
Telangana Panel Orders Tata AIA to Pay ₹1 Crore Claim
Mumbai Police Extern 10 Habitual Offenders for One Year
Mumbai Monsoon Sees Sharp Rise in H1N1, Malaria Cases
Ananya Sheth Completes Comeback In Mumbai U-13 Badminton
Mumbai Trains Election Officials Amid Statewide Electoral Roll Revision
Bombay Gymkhana Squash Finals Set After Junior Semifinals
