Insurance company asked to pay housewife Rs34.9 lakh with interest.
A diabetic cannot be refused medical compensation for heart ailments if the policy was taken prior to diagnosis. This was the judgment passed by the state consumer commission while hearing the case of a 59-year-old housewife from Ahmedabad. The commission held that if a diabetic is diagnosed with heart problems subsequent to taking a policy, the insurance company cannot reject the claim on the ground of suppression of material fact about the pre-existing disease.
The commission, while directing the insurance company to grant the claim to the patient, observed that the insurance company had failed to prove any relation between diabetes and Infrahisian block which had been detected in the woman. “It cannot be said that nowadays diabetes has become a common disease among Indians and that a person can live a normal life if it is kept under control,” the commission observed.
As per the case, Usha Joshi, a resident of Nadiad, had taken a Travel Secure policy which covered medical insurance, as she was going to USA. As it was a cashless policy, Joshi was assured that the insurance company would directly pay the expenses. The policy was active between February 11 and July 10, 2006 during which she was in USA.
Joshi, in her complaint, had stated that she was never asked to undergo a medical check-up before taking the said policy.
However, she had indicated that she was suffering from diabetes and had also given related medical history in the policy document.
On March 31, 2006, Joshi fainted and was immediately taken to hospital. She was diagnosed with Infrahisian block and was advised to get a pace maker installed in her heart at the earliest. A family member of Joshi informed the insurance company but it did not provide any service to her. However, the company informed her that she could claim the expenses after returning to India. The total expense for the operation was Rs.34.90 lakh.
On her return to India, when Joshi claimed the money, the insurance company rejected it on the ground that she had deliberately suppressed information of pre-existing disease. The company stated that Joshi was aware of her heart problem before taking for the policy.
The company even produced medical certificates to prove their claim. However, the commission found the argument baseless. It also negated the company’s claim that Joshi suffered from heart problem because she was diabetic.
After going through all the evidences produced by the insurance company and Joshi, the commission asked the insurance company to pay the medical expenses of Rs39.90 lakh at an interest of 9%. It also directed the company to pay Rs7000 for the mental agony caused to the victim and Rs3000 towards the complain procedure.
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