Liver transplant surgery; Ombudsman order against 'Care' health insurance

KOCHI: Verdict in favour of the consumer in the action of a private insurance company that denied insurance money for a liver transplant surgery on false grounds. The Insurance Ombudsman in Kochi has ordered to re-examine the claim application and determine a reasonable amount within 30 days and grant it. It was also clarified that action will be taken in case of default.

Ombudsman Pradeep Kumar Jain's action was taken in response to a complaint filed by C Ratheesh Kumar, a native of Kannammoola, Thiruvananthapuram, against 'Care' health insurance. The petitioner had joined the Care's group insurance policy of Rs 3 lakh. During this, he was diagnosed with a serious liver disease.

A private hospital in Kochi suggested an organ transplant. However, since the insurance company denied the initial cost of Rs 2.16 lakh, the remaining amount also could not be claimed. The amount was denied on the grounds that the disease was caused by drug use. However, the Ombudsman assessed that the petitioner's disease was not related to drug use. 'There is no such indication in the medical report. The claim was denied without properly examining the documents,' the order states.