The National Insurance Co Ltd (NICL) has been directed by a consumer forum here to pay Rs 92,220 to the widow of a policy holder for “arbitrarily” rejecting her claim for medical expenses of her husband’s treatment.
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The state insurance firm had rejected the claim saying he suffered from a pre-existing disease moyamoya.
The New Delhi District Consumer Disputes Redressal Forum, however, awarded the amount to the woman saying a first time diagnosis of a medical condition as a disease, which was not known to the patient till it manifested, cannot be called pre-existing.
“It is duty of the opposite party (insurance company) to bring specific evidence to prove this disease existed to the knowledge of deceased or his family. We hold that opposite party has failed to discharge this burden and denial of claim is arbitrary and thus a deficiency in service.
“We direct it to pay Rs 42,220. We also award harassment damages of Rs 50,000 to widow (Sakshi Dhingra) of deceased,” the bench presided by C K Chaturvedi said.
Delhi resident Sakshi Dhingra, in her complaint, had said her husband was duly insured from April 1, 2004 onwards for a sum of Rs one lakh under a medical policy bought from National Insurance.
On July 16, 2006, he was admitted in a comatose state at Lifeline Hospital in Priyadarshini Vihar here and was referred to Max Hospital at Patparganj here, where also his condition remained the same and he died on July 18, 2006.
She had incurred expenditure of about Rs 42,000 on his treatment and when she filed the claim, the insurance company denied it on the ground that her husband was a known case of moyamoya disease for over 12 years and thus suffered from a pre-existing disease, Dhingra had said.
The forum observed that medical records of the deceased from Lifeline Hospital showed there was no history of past illness, except that he suffered a head injury 12 years ago.
As per the medical records, his condition was diagnosed as moyamoya disease for the first time at Max Hospital.
The insurance company was proceeded against ex-parte as it had not appeared before the forum.
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