Ombudsman Orders Tata AIG to Pay Rs.1.7 Lakh Cataract Claim

AHMEDABAD :     In a significant relief for health insurance policyholders, the Insurance Ombudsman has directed Tata AIG General Insurance Company to pay ₹1.70 lakh along with applicable interest to a Gujarat resident after ruling that a cataract surgery claim could not be denied merely because a separate bill for the implanted lenses was unavailable.

The case involved Rohit Shah of Gandhidham, who had purchased a ₹10 lakh mediclaim policy from Tata AIG. During the policy period, he underwent cataract surgery on both eyes using an advanced procedure at Mehta International Eye Hospital, Mumbai.

Shah submitted a reimbursement claim of ₹2,45,474. However, Tata AIG approved only ₹75,474, deducting ₹1,70,000 towards the cost of the lenses, citing the absence of separate bills for the implants.

Shah argued that hospitals purchase intraocular lenses in bulk and do not issue individual bills for every lens used during surgery. After the insurer rejected his explanation, he approached the Insurance Ombudsman through advocate Arpit Shukla.

During the hearing, Shukla argued that the insurance policy did not contain any provision requiring a separate lens bill. He also pointed out that Tata AIG had not disputed the necessity of the cataract treatment and had already admitted the claim by making a partial payment.

Accepting these submissions, the Ombudsman ruled that the claim could not be rejected solely because a separate bill for the lenses was not produced.

The Ombudsman ordered Tata AIG to pay the remaining ₹1.70 lakh, along with applicable interest, within 30 days.

The ruling is expected to strengthen consumer rights by reinforcing that insurers cannot deny legitimate medical claims on procedural grounds when the treatment itself is undisputed.