The district consumer disputes redressal forum in Chandigarh has directed an insurance company to pay up INR 25, 000 as compensation for rejecting the medical claim of a sector 45 resident. In addition, the company was also asked to pay the claim amount of INR 54, 000 along with 9% interest per year from the date of denial, April 28, 2017.

Sanjeev Kumar Nagrath has filed a complaint against Max Bupa Health Insurance Company stating that while replacing the handle cover of a cricket bar of a customer in the first week of March 2017, he developed pain in his abdomen. He got himself checked in the government in the first week of March 2017 and was diagnosed with par umbilical hernia and was advised a surgery that was conducted under general anesthesia. He remained admitted in the hospital from March 11, 2017 to March 13, 2017. The amount spent on treatment/surgery was INR 54, 648. However, his claim was rejected by the insurance company on the grounds that he had concealed the disease as he was suffering from umbilical swelling for six to eight months.

The insurance company argued that the complainant had the disease for the last six to eight months, a fact he had concealed, and his case fell into the exclusion clause and the claim was rightly repudiated. In view of this the forum noted that the symptoms were felt in March 2017 after taking the policy. As per the record produced, it cannot be construed on the date of issuance of the policy, February 24, 2017; the complainant was suffering from hernia, which needed surgery and treatment. The forum also maintained that, “if the insurance company has any doubt with regard to the disease, it could have got the complainant medically examined to ascertain the pre-existing disease. There are many chemical reactions in the body which are not per se perceptible unless some signs and symptom appear and are reliably diagnosed by the doctor concerned.”

Based on the above arguments, the forum concluded that the grounds of repudiation are ‘illogical and are not sufficient,’ and directed the insurance company to pay up.

Source: ET Healthworld