Case of:- Ms.Megha Shah Vs The Oriental Insurance Co. Ltd.
Complaint No. AHD-G-050-1718-0183-0184-0185-0186
Insurance Ombudsman Date of award: 21/06/2017
Policy No. 530000/48/2016/507
Claim rejection for Pre existing disease
The Complainant was a member of a group policy issued to “Jain International Organisation(HNI Policy)” under the name “Group Mediclaim Tailormade Policy -Floater scheme” issued by the Oriental Insurance Co Ltd in for the period of 16/02/2016 to 15/02/2017 for a sum insured of Rs. 20,00,000/-. The Complainant was hospitalized at HCG Cancer Center for chemotherapy treatment Four times. When a claim was filed for reimbursement, the Company had rejected the claim mentioning other reason. Aggrieved by the decision she had approached the Forum for redressal.
The complainant is a beneficiary of group policy issued to “Jain International Organisation(HNI Policy)” under the name “Group Mediclaim Tailormade Policy -Floater scheme” issued by the Oriental Insurance Co Ltd for the period of 16/02/2016 to 15/02/2017 for a sum insured of Rs. 20,00,000/-. Under subject policy pre-existing disease is covered from day one as per terms and condition of the policy. The Respondent had repudiated the claim on the ground of “Other Reason” without specifying the reason in the repudiation letter.
8(Eight) claims settled by the company in current policy period and the claim filed in August-2016 & thereafter were rejected by the company, on the ground that the disease for which treatment was taken, was pre-existing and the same was not disclosed by the insured “Jain International Organisation”. If the pre-existing disease is covered from day 1, then disclosure or non disclosure of pre-existing would not have made any difference. It is also not known, why the company has earlier paid 8 similar claims under the impugned policy.
The complaint is thus admitted. Taking into account the facts & circumstances of the case and the submissions made by both the parties during the course of the personal hearing, the Respondent is hereby directed to pay in all Four claim amount after deduction of Co Payment in payment more than 50000/- as per t&c to the Complainant
