According to a press release by Consumer Education and Research Centre, Ahmedabad-based Natwar Patel had medical insurance from New India Assurance for his son Chintan
State consumer court recently ordered New India Assurance Company to grant a claim to a customer, which the company had previously rejected saying that the customer was suffering from a congenital disorder that is not covered under insurance.
According to a press release by Consumer Education and Research Centre, Ahmedabad-based Natwar Patel had medical insurance from New India Assurance for his son Chintan. Later on, Chintan was diagnosed with haemolytic anaemia and spherocytosis. It results in anaemia, jaundice and enlargement of the spleen. City-based Dr Bhauman P Maniyar operated upon him in September 2009, incurring an expense of Rs 1,23,142. Natwar lodged a claim for Rs one lakh before the insurance company. Third Party Administrator – MD India Healthcare Services (TPA) Pvt. Ltd. – rejected the claim on the grounds that Chintan's health condition was a hereditary disorder and not covered by the policy.
Dr Maniyar certified that a hereditary disease is not a congenital defect and are covered by mediclaim policies. Moreover, at the time of commencement of the policy the patient's family was unaware that he had hereditary spherocytosis. The symptoms arose only about a month before the surgery. He said the expenses were reimbursable.
Natwar approached Consumer Education and Research Society (CERS) for help. A case was filed before the Consumer Forum against the insurance company and the TPA. The Forum ruled in favour of the complainant in its order dated 15 May 2013. It directed New India Assurance Co. Ltd. to pay Rs1,23,142 with 8% interest from the date of repudiation of claim till payment. The company had to also pay Rs. 4,000 as compensation and Rs3,000 towards litigation costs.
The insurance company filed an appeal before the Gujarat State Commission. "The insurance company had not produced any evidence showing that at the time of taking the policy the complainant was aware that his son had the condition. So, the disease could not be said to be by birth and hence, it could not be said to be a genetic disorder," said Pritee Shah, chief general manager of CERC. The Commission dismissed the insurance company's appeal and upheld the order of the Forum.
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