While directing New India Assurance Company Limited to pay a total claim of Rs.2,85,833 to a city resident, along with 8 percent interest per annum, the Consumer Disputes Redressal Commission, Chandigarh, has held that an insurance claim cannot be denied on mere presumption that a person is suffering from a pre-existing disease.
The commission also directed the company to pay Rs.25,000 to the complainant as compensation for causing mental agony and harassment and Rs10,000 as costs of litigation.
Pawan Kumar, a city resident, approached the commission after he was denied claim on the ground that he had pneumonia and a known case of chronic kidney ailment since 2015, which was a pre-existing disease and the claim was not admissible under Clause 4.1 of the terms and conditions of the policy being within 48 months from the date of expiry. Pawan refuted the company’s claim by placing the documents on records that he was duly covered under the policy.
Pawan had bought New India Floater Mediclaim Insurance Policy for the first time in 2015, which was renewed subsequently. The policy was valid from May 13, 2017, to May 12, 2018, for a sum assured of Rs8,00,000.
In October, 2017, during the validity of the policy in question, Pawan fell ill. He had a fever for 10 days and was admitted to a hospital from October 24, 2017, to November 15, 2017.
He was diagnosed with thick walled cavity RML/RLL (Right lung). He was referred to the Department of Pulmonary Medicine, PGI, and was again admitted for 13 days at the hospital. Later, when Pawan submitted a total claim of Rs.2,85,833 the insurance company denied it by stating that the claimant was a case of pneumonia and a known chronic kidney disease since 2015, which was a pre-existing ailment.
Pawan also placed the record of the treatment at the PGI, which proved that he was suffering from fungal infection and diagnosed with thick walled cavity RML/RLL (Right lung). It is also recorded that during the period of the complainant’s hospitalisation, his transplanted kidney was functioning normally. Hence, no treatment of any sort was given for kidney disorder.
After hearing arguments the commission observed: “We have no option except to hold it a case of deficiency in service as well as unfair trade practice by the insurance firm.”
The commission’s order states: “It is clear from the records that treatment did not pertain to kidney problem, but a fungal infection. It has no connection or relation with the kidney disorder and is a pre-existing disease for invoking of the exclusion Clause 4.1”
The order further states: “In view of this the insurance firm is directed to pay the total claim of Rs.2,85,833 to the complainant along with 8 percent interest per annum from the date of repudiation, which is December 29, 2017, till realisation.”
