A woman who paid her medical insurance premiums for 23 years without making a claim was aghast to find that her first claim, for osteoarthritis treatment, was rejected by the insurance company. The insurer said the treatment she got was experimental. The consumer redressal forum of Rajkot district, however, ordered the insurance company to pay the claim.

Nisha Rathod, 54, took out a medical insurance policy with Rs 5 lakh assured from The Oriental Insurance Company Ltd in 2023-24. She suffered knee pain and was treated for high tibial osteotomy of the right knee at a hospital in Ahmedabad between July 24 and 28 2023. She submitted a medical insurance claim for Rs 3.90 lakh with the supporting documents. The insurer rejected this claim, stating, "It is observed that the patient was treated for osteoarthritis of the knee for which resto knee surgery was done, which is experimental or unproven treatment, including drug experimental therapy, which is not based on established medical practice in India." Shailendra Jadeja, the advocate who represented Rathod, stated, "We argued that it is not the right of insurance companies to decide what kind of treatment a patient should get. The doctor decides the best treatment for the patient, which gives protection against future risk."

The consumer court, in its order, noted that the insurance company could not provide a solid base or evidence to prove that the treatment taken by Rathod was experimental or unproven. Therefore, there was no reason not to believe the complainant. The court, in its order dated Nov 17, directed the insurance company to pay Rs 3.90 lakh with 6% interest from July 25, 2024, within two months of the order. It also ordered payment of Rs 5,000 towards the complainant's legal expenses.

(The writer is Nimesh Khakhariya)

Source:- The Times of India – 02nd December 2025 ( INSU NEWS DT 29.11.2025 TO 5.12.26)