Mumbai Consumer Commission Pulls Up New India Assurance Over Undisclosed Cataract Claim Cap, Orders Balance Payment With Interest

Mumbai, August 11, 2026: The District Consumer Disputes Redressal Commission, Mumbai Suburban, has held The New India Assurance Company Ltd. and its third-party administrator, MD India Healthcare Services (TPA) Pvt. Ltd., guilty of deficiency in service and unfair trade practice for introducing a new restriction on cataract claims without adequately informing a long-standing policyholder.

"The complainant has suffered mental agony and harassment due to the non-payment of the balance claim by the insurance firm. The complainant has, therefore, made out a case of deficiency in service and unfair trade practice on the part of the insurer and is entitled to compensation," the order reads.

The commission, presided over by Samindara R. Surve, President, and Sameer S. Kamble, Member, passed the order on a complaint filed by the Consumers Welfare Association on behalf of a policyholder.

Insurer Introduced Cataract Limit

According to the complaint, the policyholder had obtained a family Mediclaim policy from New India Assurance in 2004 and had continuously renewed it by paying the premiums. The policy was subsequently revised, and the 2012 policy introduced a new clause limiting cataract-related claims to Rs 24,000 for each eye.

The policyholder's father underwent cataract surgeries on both eyes in June and July 2014. Claims of Rs 41,642 and Rs 40,000 were submitted for the two procedures. However, the insurer paid only Rs 24,000 for each eye, relying on the newly introduced clause.

The policyholder challenged the deduction, arguing that the policy had been continuously renewed since 2004 and that the insurer had not obtained her informed consent before introducing the new restriction.

Commission Rejects Insurer's Defence

The commission noted that the insurer had failed to produce any document establishing that the modified terms and conditions of the 2012 policy had been brought to the policyholder's notice. It held that since the policy had been continuously renewed, any change in its terms should have been specifically brought to the policyholder's attention.

The commission also rejected the insurer's contention that a two-year waiting period for cataract treatment applied in the case. It observed that the policyholder had maintained continuous coverage since 2004 and, therefore, the waiting-period condition applicable to a new policy could not be invoked against her renewed policy.

Regarding MD India Healthcare Services, the commission observed that the TPA had failed to contest the complaint or place any contrary evidence on record.

"As far as MD India Healthcare Services is concerned, it has failed to contest the claim of the complainant and no contrary evidence has been brought on record by it. Therefore, the case of the complainant stands admitted by the insurance firm," the commission observed.

The commission further held that the complainant had established deficiency in service and unfair trade practice on the part of the opposite parties for allegedly violating the insurance policy norms by introducing unfavourable terms without furnishing details of the revised 2012 policy.

"The complainant has proved the case for deficiency in service and unfair trade practice on the part of the insurance firms for violating the insurance policy norms with unfavourable terms and without furnishing the details of the new policy of 2012," the order reads.

Rs 33,642 Balance To Be Paid

The commission also rejected the argument that acceptance of the amount already paid constituted a full and final settlement of the claim.

The two claims totalled Rs 81,642, against which Rs 48,000 had been paid, leaving a balance of Rs 33,642. The commission therefore directed New India Assurance to pay the balance amount with 9 per cent annual interest from April 1, 2015, until payment or realisation.

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In addition, the insurer and MD India Healthcare Services were jointly and severally directed to pay Rs 10,000 as compensation for mental agony and harassment and Rs 5,000 towards litigation costs.

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