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Precancerous Condition Triggers Insurance Payout Victory
17 May
Summary
- Precancerous condition coverage confirmed by consumer commission.
- Woman awarded ₹43,090 plus interest and compensation.
- Insurer denied claim citing lack of full cancer diagnosis.
A consumer commission in Mohali has mandated New India Assurance Company Limited to reimburse a local woman for robotic surgery expenses, asserting that precancerous conditions are eligible for insurance coverage. The ruling came after the insurance company partially denied Seema Goyal's medical claim for treatment received at Fortis Hospital, Mohali, in October 2024.
The hospital had billed ₹2.12 lakh for Goyal's treatment. While the insurer approved ₹65,000 for surgery and paid ₹15,972 for other expenses, they rejected the remaining ₹43,090. The company's defense was that robotic surgery coverage was limited to malignant cancer and specific ailments, and Goyal had not been diagnosed with cancer.
However, the commission reviewed Goyal's medical records, which indicated a diagnosis of "Atypical hyperplasia on endometrial biopsy." The bench noted this condition carries a significant risk of progressing to endometrial cancer, classifying it as precancerous. Consequently, the commission found no justification for deducting the disputed amount, ordering the insurer to pay the ₹43,090 with 9% annual interest from April 3, 2025, along with ₹20,000 for mental distress and legal costs.
