Mumbai man’s eight-year battle with insurance firm gets him ₹16.5-lakh claim

A Mumbai man wins ₹16.5 lakh insurance after a long battle post-accident left him blind in one eye, highlighting flaws in disability claim assessments.

MUMBAI: Eight years after a road accident left him blind in one eye, a 49-year-old Mumbai man has finally won ₹16.5 lakh in insurance compensation. “My retina has completely detached, leaving my eye clouded and without vision,” he said. But the fight wasn’t just medical—it was against an insurance system that dismissed his pain and denied his rightful claim.

Chetan Tolia underwent surgeries after a 2017 road accident in Hyderabad

Experts say the man’s case underscores the emotional and legal toll many policyholders face and highlights growing calls for reform in how insurers assess disability and settle claims.

After a road accident in Hyderabad in 2017, Chetan Tolia, a jewellery businessman from Ghatkopar, underwent multiple surgeries, including a failed corneal graft and treatment for retinal detachment. The vision in his left eye was declared permanently and irreversibly lost. Under his personal accident policy with The New India Assurance Company Limited, he was entitled to 50% of the insured amount— ₹16.5 lakh—for total loss of sight in one eye.

But the insurer paid him just ₹4.5 lakh, citing a certificate from J J Hospital that mentioned “30% disability”. The New India Assurance Company Limited claimed this indicated only partial vision loss, justifying a reduced payout far below the policy’s promised amount.

However, the 30% figure referred solely to impairment in the affected eye—not total visual capacity. The same certificate described a “complete mobile retinal detachment” and noted the condition as “permanent, non-progressive and not likely to improve.” Despite this, the insurer treated the percentage as a reflection of overall disability, overlooking the absence of any assessment of binocular vision or functional impairment.

“The certificate issued by J J Hospital had an ambiguity—whether the disability percentage applied to one eye or overall sight,” said Dr M S Kamath, secretary, Consumer Guidance Society of India. “The insurer selectively used the number without considering the medical context. A permanently non-functional eye with complete retinal detachment is total vision loss. The policy refers to loss of sight—not percentages—and the report was misused to deny the full claim.”

Tolia said that the company had reduced his pain and medical reality to a statistic. “It was clearly documented that my eye was beyond recovery, yet one ambiguous figure was used to strip me of my right,” he said.

Over the years, Tolia appealed multiple times to the company’s grievance cell and the insurance ombudsman but got no relief. Throughout this period, he battled deteriorating health, vision loss, and the psychological toll of being dismissed by a system meant to support him.

In April 2025, the District Consumer Disputes Redressal Commission, Mumbai Suburban Additional, finally ruled in his favour. It observed that the insurer had “wrongly interpreted the medical evidence” and had failed to consider the policy’s clear clause stating that complete loss of sight in one eye entitled the policyholder to 50% of the sum insured. The Commission ordered New India Assurance to pay ₹16.5 lakh with 6% interest from 2017, plus ₹35,000 for mental agony and litigation costs.

The insurance company did not respond to HT’s email request for comment.

“The JJ certificate was never meant to evaluate overall disability—it merely quantified the affected eye,” said Dr Kamath. “Interpreting it otherwise was a deliberate act of misrepresentation.”

Tolia’s case has reignited calls for stronger regulation of India’s private health insurance sector. “There’s a troubling trend of insurers rejecting valid claims by misusing medical terminology and outdated assessment criteria,” said Dr Kamath. He pointed to the lack of standardised guidelines and the absence of independent medical arbitration, which allows insurers to act as both assessor and adjudicator.

Calling for broader reform, Nilesh Panchal, a human right activist working for healthcare said, “The Insurance Regulatory and Development Authority of India (IRDAI) must step in with clearer enforcement policies, penalties for bad-faith denials, and transparent communication practices. Without these safeguards, policyholders—especially those recovering from serious illnesses or injuries—remain vulnerable to exploitation.”

Panchal added that legal literacy around insurance policies remains low, particularly among middle- and lower-income groups, leaving people unaware of their rights or the basis for denial. “The imbalance of power between insurers and claimants is stark,” he said. “What’s needed is not just regulation, but accountability, medical clarity, and empathy built into the system.”