Kochi Ombudsman Centre
Case No. IO/KCH/GI/22/2006-07
Ms. Raseetha P
Vs
Oriental Insurance Co. Ltd
The complaint under Rule 12(1)(b) read with Rule 13 of the RPG Rules, 1998 relates to repudiation of a medical insurance claim by the respondent under its Good Health Insurance policy. The complainant’s current policy was for the period 22.3.2005 to 21.3.2006. She had earlier taken a mediclaim policy, which had a break in renewal, and therefore the current policy was treated as a fresh one. The insured had undergone inpatient treatment at Muthoot Medical Centre, Kozhencherry from 16.9.2005 to 20.9.2005 for Cervical spondylosis.
The insurer had repudiated the claim citing exclusion under the “pre-existing diseases” clause. The insured stated before this Forum that she had, some time earlier, some pain on the hand for which she had consulted the Doctors at the same hospital and it was with the same OP ticket that she had gone to the hospital in Sept.2005 when only the disease was diagnosed as Cervical spondylosis.
The insured contended that she was unaware of her problem as of Cervical spondylosis till the consultation in the hospital in Sept.2005. The insurer had based their decision on the opinion of a panel Doctor which stated that the problem could have pre-existed in her atleast for a period of 175 days. In any case, in the absence of a proper diagnosis till Sept.05, the insured could not be said to have been aware of it and hence the insurer was asked to settle the claim subject to proper verification of bills and all compulsory deductibles.
