Insurance firm directed to pay claim to consumer

Tribune News Service

Amritsar, June 25

The District Consumer Disputes Redressal forum has directed an insurance company to pay Rs 89,081 as medical insurance claim along with Rs 2,000 as litigation expenses.

Surinder Peshawaria, a resident of the Airport Road area had filed a complaint against the Oriental Insurance Company stating that he purchased a mediclaim policy on February 18 last year which was valid for one year for him and his wife. He said he was admitted to a private hospital for treatment of intraparenchymal hemorrhage (brain hemorrhage) during the validity of the insurance. The complainant spent Rs 89,081 on the treatment. He complained that his claim was repudiated stating that the policy was in second year and the complainant was a known case of coronary artery disease after 2005, type-2 diabetes mellitus for the last four years and hypertension from 2005.

The complainant claimed that the policy was in its third year as he had purchased two policies prior to the present one. He said intraparenchymal hemorrhage had no relation with the said diseases and and thus could not be considered as pre-existing disease.

The company in its reply stated that as per the exclusion clause, the company would not be liable to make any payment under this policy in respect of any expenses incurred by any insured person in connection with any pre-existing health condition or disease, when the cover incepts for the first time, since pre-existing diseases were excluded up to three years of the policy being in force continuously. The reply in this case was the policy was a second-year policy and the disease was found to be pre-existing which was not payable since there was a waiting period of three years for the same.

The forum observed that the consumer was suffering from hypertension and diabetes prior to the issue of the insurance cover in dispute. It said hypertension and diabetes were not a material disease and therefore, non-disclosure thereof was not concealment. The forum said it was usual with the insurance company to show all types of green pesters to customer for selling policies and when it comes to payment of claim, they invent excuses to deny it.