Health Insurance Co. to pay for restoknee surgery: Consumer court

Insurance Medical Insurance Health policy
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Last Updated on November 20, 2019 by The Health Master

A consumer court has rejected an insurer’s argument that restoknee surgery is an unproven and experimental therapy and ordered it to pay mediclaim to the patient for the surgery.

According to case details, Navrangpura-resident Jashwantbhai Patel was suffering from osteoarthritis and underwent restoknee surgery for the trouble in his right knee in August 2018.

He paid Rs 3.04 lakh for the treatment. After being discharged, he claimed the amount from the United India Insurance Co Ltd from which he had been taking Mediclaim regularly for nearly two decades.

The insurer rejected his claim saying that the restoknee surgery is an unproven and experimental treatment and clause 4.15 of policy conditions said that claim cannot be granted for such a treatment. Patel sued the company with the Consumer Dispute Redressal Forum, Ahmedabad (city) and placed the doctor’s discharge summary, which in detail mentioned the procedure of restoknee surgery.

The company objected to Patel’s complaint, but the court took into consideration the communication that took place between the insurer and the patient, where the company had first admitted that the claim for restoknee surgery could be cleared, but still insisted that the patient should apply to review his file.

Later, the company rejected the claim. The court termed it double standard and arbitrary decision on part of the company. It was unfair trade practice, the court said.

The court further said that restoknee is not an ordinary therapy, but it is a surgery undertaken by a specialist doctor in operation theatre. It ordered the insurer to pay the claim to the patient with Rs 13,000 extra amount towards compensation for harassment and legal expenditure.