Insurance firm fined for repudiating medical claim, to pay Rs 3.35 lakh

Tribune News Service

Amritsar, April 22

The district consumer disputes redressal forum has directed an insurance company to pay Rs 3,35,678 along with Rs 2,000 as litigation expenses to a resident whose medical claim was earlier repudiated.

Rajesh Parbhakar, a resident Chheharta, had filed a complaint against The Oriental Insurance Company Ltd, stating that he had purchased a medical insurance worth Rs 5 lakh for which he had paid a premium of Rs 6,830.

He stated that during the validity of the insurance, he was admitted to a hospital for treatment and was diagnosed with coronary artery disease (double vessel disease) and heart-related problems.

During the treatment, he underwent coronary angiography and coronary angioplasty and charged Rs 3,35,678. He complained that the opposite party rejected his claim on the ground that the claim was not admissible since the complainant was a known case of hypertension as mentioned in the ECG report. Further, it was alleged in this letter that the complainant was found to be suffering from diabetes as well.

The opposite party, in its reply, stated that the treatment of any medical condition, which has pre-existed at the time of the inception of insurance cover, is excluded for such insured person up to three years. The firm stated that its investigation revealed that the patient was admitted to a private hospital prior to purchasing policy with a case of CAD, diabetes, hypertension and had undergone treatment for the same. It stated that due to “non disclosure of material facts and as per terms and conditions of the present policy” the claim was not maintainable.

The forum observed that the opposite party could not produce any evidence to the effect that complainant had knowledge about his disease of hypertension prior to obtaining the policy.

It stated that the only ground on which the claim of the complainant had been repudiated by the opposite party wais that the complainant was suffering from hypertension prior to the issue of the insurance cover in dispute. It stated that hypertension is not a material disease and therefore, non disclosure thereof is not concealment.

The forum stated that there was no bar on the opposite party to get the thorough medical check up conducted of the insured at the time of issuing issuance cover. The opposite party had the right to cancel the policy if it doubted or found any information supplied by the insured being false or wrong.