Chennai Ombudsman Centre
Award No. 11.08.1058 / 2006 – 2007
Shri. G. S. Venkataraman
Vs
The Royal Sundaram Alliance Ins. Co. Ltd
The complainant represented that he had taken a Health Shield Policy with Royal Sundaram Alliance Co. Ltd, for the period from 05.04.05 to 04.04.06. He was hospitalized from 17.02.06 to 19.02.06 and subsequently from 06.03.06 to 08.03.06 for hemithyroidectomy and Completion thyroidectomy with nodal dissection respectively. His claim was repudiated on the ground of pre-existing disease.
The insurer contended that Histopathology report of the insured revealed that the complainant/insured had Papillary Carcinoma, infiltrating the perithyroidal soft tissue, right hemithyroid and this Papillary Carcinoma Thyroid could not have developed over a short span of time and it would have taken a long time and hence their repudiation on the grounds of pre existing exclusion is in order.
It was very clear from the definition of the term ‘disease’ that for a disease to exist there should be a manifestation by way of a set of symptoms and signs. Since there was no evidences of any manifestation of the disease by symptoms or signs prior to 05.04.2005 and the insurer also failed to establish that there was manifestation of symptoms existing in the insured at the time of proposing for insurance in April 2005, the Ombudsman directed the Insurer to settle the claim as per policy conditions and allowed the complaint.
