Mumbai Ombudsman Centre
Complaint No.GI-036 of 2005-2006
Shri Pradeep Chibber
V/s.
The New India Assurance Company
Smt. Vimla Vedprakash Bhai had taken an Overseas Mediclaim Policy for her overseas trip to Auckland, New Zealand to visit her daughter. At the time of taking the policy Smt Vimla Vedprakash Bhai disclosed about her diabetes and blood pressure and also submitted an ECG report to New India. On 10.12.2004 while she was in Auckland she developed fever and was admitted to Auckland District Health Board, Infectious hospital from 10.12.2004 to 29.12.2004 for Haemophilus Parainfluenzae Endocarditis.
When she preferred a claim with Coris, Paris they rejected the claim due to preexisting conditions. It is also confirmed as per her admission note that Smt Bhai had a Transient Ischaemic Attack causing left arm and right face weakness and C.T. a head was performed which showed some old Ischaemic changes consistent with her age. The forum noted that Diabetes is one of the most important predisposing factors as also referred to by some other researchers.
This analysis make it clear that predisposing factors were intertwined in a complicated manner of which some of the existing illnesses played a major part. At the same time a pointed reference made by the specialists at Auckland District Health Board identified bacterial infection after only a series of tests. It would therefore, be relevant to consider atleast 50% of the admissible claim amount being payable for a possible independent genesis of this disease which could be diagnosed through tests followed by a package of treatment.
