INSURANCE OMBUDSMAN DECISION
In the matter of Mrs. NeelimaSethi
Vs
Bajaj Allianz General Insurance Company Ltd. (New Delhi)
The complainant had purchased a Travel Insurance Policy for Travel Elite Silver Plan for the period from 07.05.2016 to 04.08.2016 of Bajaj Allianz General Insurance Company Ltd. The complainant was hospitalized in Liverpool Hospital on 12.06.2016 and discharged on 17.06.2016 for the treatment of Acute Myocardial Infraction. The complainant had stated that the Insurance Company had repudiated the claim under standard Travel Policy Exclusions vide clause No. 2.4.12 which reads as “Any medical condition or complications arising from it which existed before the commencement of the policy period, or for which case, treatment or advice was sought, recommended by or received from a physician”. The complainant had submitted a certificate issued by the treating Doctor Liverpool Hospital stating that the complainant had a past history of hyper-tension and dyslipidaemia which are very common condition and considered two of the many risk factors for heart disease, she was not having any history of Ischemic Heart disease. The team of hospital opined that the acute myocardial infraction is not directly caused by her past medical history. The treating Doctor also reported that complainant had a stress test 2 years ago which was normaland opined that previous IHD history and her current conditions were not directly caused by a known past medical history of heart disease.
The Insurance Company had repudiated the claim on the grounds of standard Travel Policy Exclusions as per clause No. 2.4.12 which reads as “Any medical condition or complications arising from it which existed before commencement of policy period, or for which case, treatment was sought, recommended by or received from a physician”. The current ailment (Myocardial Infraction) is complication of pre-existing ailment (Hypertension).
The case was heard by me on 17.01.2017 when the complainant as well as the Insurance Company presented and pleaded their case. During the course of hearing the complainant had stated that while stay at Liverpool, the complainant was hospitalized for the treatment of Acute Myocardial Infraction. The complainant had further stated that the treating Doctor of Liverpool hospital had issued a certificate saying that the complainant had a past history of hypertension and dyslipidaemia which are very common condition and considered two of many risk factors for heart disease. She was not having any history of Ischemic Heart Disease. The team of Doctors of the Hospital had observed that the Acute Myocardial Infraction is not directly caused by her past medical history. The treating Doctor had also reported that the complainant had a previous stress test 2 years back which was normal and opined that previous IHD history and her current conditions not directly caused by a Known past history of heart disease.
The representative of the Insurance Company had reiterated that the current ailment “Myocardial Infraction” is complication of pre-existing ailment (Hypertension). I have gone through the pleadings and documents presented from both the sides. I find that the Insurance Company failed to prove through cogent and reliable documents in support of their contention that the current ailment was related to pre-existing disease, hence in the absence of same, the claim of the Complainant is found to be admissible. Accordingly, the Insurance Company is directed to settle the claim as admissible as per the terms and conditions of the policy. The complainant is advised to submit complete bills to Insurance Company for the settlement of claim with in a period of 30 days of receipt of the bills.
