Mohali: Consumer panel directs insurer to refund robotic surgery claim

Goyal had approached the consumer panel after the insurance company partially rejected her medical claim arising from treatment at Fortis Hospital, Mohali, in October 2024

Holding that a precancerous condition could not be excluded from insurance coverage merely because cancer had not fully developed, the district consumer disputes redressal commission, Mohali, has directed New India Assurance Company Limited to reimburse a Mohali woman for expenses incurred on robotic surgery at a private hospital.

The insurer was also directed to pay ₹20,000 towards mental agony, harassment and litigation expenses. (HT File)

The commission, comprising president S.K. Aggarwal and members Paramjeet Kaur and Lt Col Jasbir Singh Bath, ordered the insurer to pay ₹43 K along with interest and compensation to complainant Seema Goyal, a resident of Sector 68, Mohali.

Goyal had approached the consumer panel after the insurance company partially rejected her medical claim arising from treatment at Fortis Hospital, Mohali, in October 2024.

The hospital raised a bill of ₹2.12 lakh for the treatment. The insurer approved ₹65,000 towards surgery charges and later paid only ₹15,972 for medical investigations, pharmacy and related expenses. The complainant alleged that she paid the remaining amount from her own pocket and sought reimbursement of ₹43,090, which she claimed was still pending.

In its reply, the insurance company stated that robotic surgery expenses were admissible only for malignant cancer, brain, heart and spine-related ailments under the policy terms and conditions. Since the complainant was not diagnosed with cancer, the insurer argued that the deduction was justified.

After examining the medical records, the commission observed that the complainant had been diagnosed with “Atypical hyperplasia on endometrial biopsy”. The order noted that the condition has a significant connection with cancer and is considered a precancerous condition with a risk of progressing to endometrial cancer.

The commission held that the condition was covered under Clause D(9) of the policy and observed that there was no justification for deducting the disputed amount from the claim.

The bench directed New India Assurance to pay ₹43,090 with 9% annual interest from April 3, 2025, within 30 days. The insurer was also directed to pay ₹20,000 towards mental agony, harassment and litigation expenses.