INSURANCE COS CAN’T DENY CLAIMS ON CONCEALING OF DISEASE: CONSUMER COMMISSION

News and Reviews - An insurance company cannot deny mediclaims on the ground of concealment of pre-existing disease unless the insured person undergoes operation or remained in a hospital just before purchasing a policy, Delhi Consumer Commission has held.

“The crux is that until a person is hospitalised or undergoes operation in near proximity of obtaining mediclaim policy or say year or two before it, he is not supposed to disclose any day to day problem or normal wear and tear of human life particularly in modern times, where a person lives a stressful life,” the Commission said.

Coming down heavily on the insurance companies for repudiating claims, Commission President Justice J D Kapoor said, “They cannot take advantage of its act of omissions and commissions as they are under an obligation to ensure before issuing mediclaim policy whether the person is fit to be insured or not.”

The Commission’s observations came while dismissing an appeal by Oriental Insurance Company Ltd against a district forum order, directing it to pay Rs 1.07 lakh to one Mohinder Singh as compensation including insured amount of Rs one lakh.

Singh, who purchased the policy on July 10, 2000 for one year, was later hospitalised following chest pain. The doctors carried out an angioplasty on him, incurring cost of Rs 1.34 lakh on him.

“It appears that insurance companies do not discharge their obligation properly as half of the population is suffering from such malaise and they would be left with either no or very little business,” it said.

The Commission rejected the insurance company’s contention that it repudiated claim as Singh had concealed the fact regarding his treatment for alleged coronary artery disease before purchasing the policy.

“A person comes to know about the medical terminology of a particular disease when he lands in a hospital and undergoes treatment or operation. If a person had suffered heart attack or got treatment for a particular disease say 10 to 20 years before and has been leading normal life, he is not supposed to disclose the factum of having undergone treatment,” it said.

Insurance I Opener - It is not as simple as it sounds. Yes, if a policy is purchased and customer is not aware of any Pre-Existing Conditions (also known as PED), then the claim will have to be paid by the Insurance Company. However, if a customer is aware (Directly or Indirectly - say under regular medication for a disease etc.) and ignores to put the fact on the Insurance Proposal Form, then Insurance Company has a right to deny the claim.

However, when claim is filed, rejection or acceptance is broadly based on the Doctor / Medical Reports and judment of the Claims Manager, sitting far away from the scene, thus leading to subjective decision rather than objectivity. Thus, it is recommended to take your Insurance Plans, be it Health Insurance, Family Insurance, Travel Insurance, Corporate Insurance throug IRDA approved Brokers only like Bonsai Insurance Broking, who will assess your risk objectivley and will help you during unfortunate claims.