Insurance Ombudsman directs National Insurance to pay for dental surgery

HYDERABAD: In a landmark decision, the Insurance Ombudsman has ruled in favor of a retired bank employee, directing the National Insurance Company Ltd. to settle a claim for dental surgery and root canal treatment. The case, which sets a significant precedent, was brought forward by the Association of Retired IOB’s Employees (ARISE).

The claim, amounting to Rs. 70,847, was initially repudiated by National Insurance, which categorised the necessary dental work as a “cosmetic surgery.” The treatment was for the spouse of ARISE member K Durga Sambasiva Rao covered under a Family Floater Insurance Policy of Rs 4 lakh, initiated by the Indian Banks’ Association (IBA) for retired bank employees.

ARISE, through its persistent efforts over a period of two years, argued that the claim was valid under policy clause 2.12. This clause explicitly covers “dental treatment” including “treatment related to teeth or structures supporting teeth including examinations, fillings (where appropriate), crowns, extractions, and surgery.”

After hearing arguments from both sides last week, the Insurance Ombudsman based at Hyderabad issued an award on Tuesday, in favor of the insured member. The Ombudsman’s decision acknowledged the merit of ARISE’s interpretation of the policy conditions, overturning the insurance company’s repudiation.

“This is a unique award in the history of consumer forums or the Ombudsman regarding dental surgery claims under the IBA policy,” said CSR Anjaneyulu, deputy general secretary of ARISE. “This ruling serves as vital precedents that will help bona fide claimants get relief for dental treatment.” The National Insurance Company has been directed to settle the claim within 30 days of the order.