Insurance Ombudsman Directs National Insurance: In a landmark decision, the Insurance Ombudsman in Hyderabad has ruled in favor of a retired bank employee, directing National Insurance Company Ltd. to settle a claim for dental surgery and root canal treatment. The case, brought forward by the Association of Retired IOB’s Employees (ARISE), sets a significant precedent for policyholders seeking legitimate medical claim settlements under Family Floater Insurance policies.
The claim, totaling Rs. 70,847, was initially rejected by National Insurance on the grounds that the dental procedures were classified as “cosmetic surgery.” However, the insured, K Durga Sambasiva Rao, had coverage under a Family Floater Insurance Policy of Rs. 4 lakh, initiated by the Indian Banks’ Association (IBA) specifically for retired bank employees.
Insurance Ombudsmans Award and Key Findings
Following persistent efforts by ARISE over two years, and after careful review of the case, the Insurance Ombudsman in Hyderabad ruled in favor of the claimant. The Ombudsman recognized that the policy clause 2.12 explicitly covers dental treatments, including:
- Examinations
- Fillings (where appropriate)
- Crowns
- Extractions
- Surgery related to teeth or supporting structures
The decision directly refuted the insurance company’s characterization of the procedure as cosmetic, emphasizing that the treatment was medically necessary. The Ombudsman directed the National Insurance Company Ltd. to settle the claim within 30 days of the order.
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Significance of the Ruling
According to CSR Anjaneyulu, Deputy General Secretary of ARISE, this ruling represents a unique and important precedent:
“This is a unique award in the history of consumer forums or the Ombudsman regarding dental surgery claims under the IBA policy. This ruling serves as a vital precedent that will help bona fide claimants get relief for dental treatment.”
This judgment is expected to empower policyholders and consumer advocacy groups to challenge unjust claim rejections, especially where policy terms clearly include the treatment in question.
What Policy Clause 2.12 Covers
Policy Clause 2.12 explicitly includes dental treatment and covers:
- Routine dental examinations
- Fillings and crowns
- Tooth extractions
- Surgeries related to teeth and supporting structures
This coverage is particularly important for family floater insurance plans offered by institutions like the Indian Banks’ Association, which are designed to provide comprehensive health coverage for retired employees and their dependents.
Conclusion
The Insurance Ombudsman’s decision marks a milestone in consumer protection, setting a strong precedent for future dental surgery claims under similar policies. By overruling the insurance company’s initial denial and mandating prompt settlement of the claim, the ruling strengthens the rights of policyholders and reinforces the importance of fair insurance practices.
The case underscores the significance of clear policy language and the vital role of consumer advocacy groups such as ARISE in safeguarding the interests of insured individuals.
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FAQ: Dental Surgery Claim under IBA Family Floater Insurance
1. Why was the claim initially rejected by National Insurance?
National Insurance classified the dental surgery and root canal treatment as “cosmetic surgery,” which they claimed was not covered under the policy.
2. What policy clause supports the claim?
Policy clause 2.12 explicitly covers dental treatment, including surgeries related to teeth and supporting structures, along with examinations, fillings, crowns, and extractions.
3. Who is eligible under the Family Floater Insurance Policy?
The IBA Family Floater Policy covers retired bank employees and their dependents, providing a comprehensive sum insured of Rs. 4 lakh, including coverage for medical and dental treatments.
4. How does this ruling impact future dental claims?
This ruling sets a strong precedent, making it easier for policyholders to claim medically necessary dental treatments and discouraging insurers from wrongly categorizing such procedures as cosmetic.
5. What is the time frame for claim settlement now?
Following the Ombudsman’s award, the National Insurance Company has been directed to settle the claim within 30 days of the ruling.
