Office of the Insurance Ombudsman, Kochi
Complaint No.IO/KCH/GI/11-004-251/2008-09
Shri T.X.Sebastian
Vs
United India Insurance Co.Ltd.
Award dated 17.12.2008
A Universal Health Insurance Policy was issued to Win Centre, a social and charitable organization for the period 01.07.2007 to 30.06.2008 covering 2,144 BPL families including that of the complainant. On 28.11.2007, the complainant’s son Sharon was admitted in Indira Gandhi Hospital and treated an in-patient up to 01.12.2007, where the disease was diagnosed as epilepsy. The claim was repudiated on the ground of preexisting disease. It was submitted by the insurance company that the illness set in within 5 months of taking the policy.
The treating doctor has not filled in the column regarding the history of illness. Hence the disease might have been congenital or preexisting. So they have referred the file to a panel doctor who also opined that the illness may be congenital or pre-existing. Based on these, they have repudiated the claim invoking condition 4.1 of the policy. It was submitted by the insured that his son is now aged 10 and he never had this illness before. They also produced a certificate from the treating doctor who is a MD in Medicine and Neuro, stating that the illness occurred for the first time and not a congenital or pre-existing disease.
It can be seen that the panel doctor of the insurance company has not given a definite opinion whereas the treating doctor, who is a specialist, has given a definite opinion that it is not pre-existing or congenital. Hence the opinion of the treating doctor has to be considered rather than the desktop opinion of the panel doctor. The complainant is, therefore, eligible for the claim amount and an award is, therefore, passed directing the insurer to pay the eligible claim amount of Rs.3,905/- with interest @ 8% p.a. and a cost of Rs.500/-.
