The General Insurance Council has given a uniform definition for pre-existing diseases. These get covered from the fifth year of the policy. But still the insurance companies and their third-party administrators (TPAs) try to avoid paying legitimate claims.
When Bharucha lodged a claim, it was repudiated by Heritage Health TPA, on the ground that there was medical history of hypertension and diabetes for the past 10 years, and was not payable as the policy was still within its fourth year. This was incorrect, as the policy had already completed four years and the problem arose during the fifth year. Bharucha challenged the repudiation by filing a complaint before the Consumer Forum for South Mumbai District.
After several arguments the insurance firm challenged this order before the Maharashtra State Commission. The only contention was that under the policy, the total sum insured was Rs 2 lakh but would be limited to 50 per cent for each claim.
The State Commission, in its judgment of May 6, 2015, delivered by presiding member Shashikant Kulkarni for the bench along with member Khamatkar observed the clause restricting the claim to 50 per cent of the sum insured was a note added to one of the clauses of the policy, whereas the policy schedule stated the claim payable would not exceed the sum insured.
The Commission concluded the note restricting the claim was not enforceable, since it was contrary to the policy schedule. Accordingly, the Commission rejected the insurance company’s appeal and upheld the order passed by the District Forum.
