Firm told to pay claim for kidney treatment in Mohali hospital

Tribune News Service

Chandigarh, May 20

Occasional treatment for hypertension (high blood pressure) cannot be a conclusive ground to say that the patient had pre-existing serious ailment. By observing this, the District Consumer Disputes Redressal Commission, Chandigarh, has directed an insurance company to pay a claim of Rs 1,61,181 to a woman for her kidney treatment which was denied on the ground of concealing the previous ailments.

The commission has also directed the company to pay Rs 15,000 to the complainant towards compensation for causing harassment along with litigation cost of Rs 10,000.

Rajeev Gupta of Ambala had approached the commission after the company refused to reimburse the claim of treatment of his wife. In the complaint, Gupta said he and his wife Nisha Gupta obtained a health insurance policy from M/s. Manipal Cigna TTK Pro Health Insurance. His wife, Nisha Gupta, was admitted to Mayo Health Care Super Speciality Hospital, Mohali, on February 13, 2020, for kidney problem and she was discharged on February 17, 2020.

He said he showed the policy document to the hospital for claiming the medical expenses, but the company refused to make any payment to the hospital, as such the complainant had to pay the medical bills of Rs 1,61,181 from his own pocket. He said the company repudiated the medical claim saying that Nisha was having some existing medical conditions and had also remained hospitalised but she did not disclose all this while proposing for the policy.

After hearing the arguments, the commission said merely visiting or consulting any hospital or the PGIMER, Chandigarh, regarding any medical problem/condition did not prove that the person was already suffering from a pre-existing serious disease. Also while selling the policy to the potential clients, the insurance company, as per their rules and procedure, have an obligation to ensure that the policy buyer is in a state of fit health to be eligible to buy the policy.

In this case, the company has sold the policy to the complainant and subsequently repudiated the benefit of the policy taking the ground of pre-existing illness/disease. The occasional treatment for hypertension or high blood pressure cannot be a conclusive ground to say that the patient had a pre-existing serious ailment. More so, hypertension is a common ailment, which can be controlled by medicines.

The company failed to prove by leading concrete documentary evidence that the claimant/insured was already suffering from any serious ailment before taking the policy in question. Hence, the act of the company in repudiating the genuine claim of the complainant amounts to deficiency in service, which not only caused a huge financial loss to the complainant, but also caused him immense harassment and mental agony.

What panel observed

“The occasional treatment for hypertension (high blood pressure) cannot be a conclusive ground for denying claim”, says District Consumer Disputes Redressal Commission, Chandigarh.

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