Mumbai’s District Consumer Disputes Redressal Commission has directed New India Assurance and its third-party administrator to settle a cataract insurance claim dispute, highlighting issues of undisclosed policy modifications and unfair trade practices.
Mumbai’s District Consumer Disputes Redressal Commission has ordered New India Assurance and its third-party administrator, MD India Healthcare Services, to pay a policyholder the balance of a cataract claim with interest after ruling that the insurer had introduced a new cap without properly informing her. The commission said the insurer’s conduct amounted to deficiency in service and unfair trade practice, and added compensation for mental agony and litigation costs.
According to the complaint brought by the Consumers Welfare Association on behalf of the policyholder, the family mediclaim cover had been in force since 2004 and had been renewed continuously. The dispute arose after the 2012 version of the policy introduced a limit of Rs 24,000 for each eye in cataract claims. When the policyholder’s father underwent surgery on both eyes in June and July 2014, the insurer accepted the claims only up to that ceiling, despite bills of Rs 41,642 and Rs 40,000.
The commission, presided over by Samindara R. Surve and Sameer S. Kamble, rejected the insurer’s argument that the revised terms had been binding. It found no document showing that the altered conditions in the 2012 policy had been brought to the policyholder’s attention, and said any material change in a long-running renewed policy should have been clearly disclosed. The panel also dismissed the insurer’s reliance on a two-year waiting period for cataract treatment, saying that provision could not be used against an uninterrupted policy that had been renewed since 2004.
The commission further noted that MD India Healthcare Services had not contested the complaint or produced contrary evidence. It held the insurer and the TPA jointly and severally liable to pay the outstanding Rs 33,642, with 9 per cent annual interest from April 1, 2015 until payment or realisation, as well as Rs 10,000 for harassment and Rs 5,000 in costs. The case adds to a string of recent consumer rulings involving cataract-related claims and eye treatment, including another January decision in Gujarat in which New India Assurance was directed to pay a mediclaim for squint correction surgery after the court found the procedure to be medically necessary rather than cosmetic.
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