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Forum finds insurance firm's clause 'sick'

Saturday, 21 December 2013 - 2:12am IST | Place: Pune | Agency: DNA
Company had rejected claim of patient who 'failed' to disclose preexisting ailment

Merely having pain doesn’t mean a policyholder knew what disease he was suffering from and hence it also doesn’t mean he intentionally did not disclose a pre-existing disease, State Consumer Disputes Redressal Commission has ruled.

Pune-based citizen Ashok Ahuja had bought a mediclaim insurance policy from United India Insurance Company in June 2008 and had renewed it till June 2010. 

In January 2010, Ahuja took treatment for neurological claudication and submitted a claim of Rs3.08 lakh. The insurance company, however, rejected his claim saying he did not disclose his preexisting ailment and hence the treatment cost could not be reimbursed.

Ahuja filed a complaint with the Pune District Consumer Disputes Redressal Commission, but it was dismissed. He filed a due appeal in the state forum against the company where his son pleaded on his behalf.

The insurance company’s argument was based on two points — that Ahuja was examined at the Bombay Hospital which is sufficient to attribute to the insured the knowledge that he was suffering from ailment for three years and not for three months. The company also pointed he had taken out a magnetic resonance imaging (MRI) of lumbosacral spine in October 2008.

The certificate issued by Dr Kundanani of Bombay Hospital suggested that Ahuja had been suffering from leg pain for three years. Later, Dr Kundnani amended the certificate stating he was suffering for three months and not three years. Forum, presided by Justice RC Chavan, however, pointed that even if one assumed Dr Kundanani changed his mind and amended his certificate where the period was reduced from three years to three months, it still did not say the policyholder knew what he was suffering from.

“Let us assume that this letter was issued with an intention to help the insured and that the insured was suffering from this problem for the past three years. Still, we fail to understand as to how mere complaints of persistent non-resolving pain in left leg could make a layman like the complainant imagine that he was suffering from some disorder of nervous system, which he should have disclosed in the proposal form,” forum noted in its order.

The two-member forum also pointed that Ahuja had submitted the MRI scan in 2008 when he had availed of cashless facility. The insurance company should have discovered if there was anything amiss and should have cancelled his policy in 2008 itself for not disclosing ailment, since the scan was available with them, the forum pointed.

Most importantly, what really seemed to have gone against the company was the blank proposal form signed by the policyholder. The insurance company submitted the proposal document to show that the policyholder had not declared the disease while taking policy, but the forum ruled that it was shocking the company was asking policyholders to sign blank proposal forms.

“It is shocking to note that except for the first page which are having names of family members of the insured, the entire form was blank. There is no justification as to why the company provided insurance cover on the basis of such blank proposal form,” the forum said. 

“The company collects premium from persons without any hesitation. People who approach the insurance company with the hope that the company will help them in times of difficulty, but later on insurance company feels no compunction when it declines to fulfillment of its commitments and raises all sorts of defence. This is extremely tragic,” the forum said while awarding full reimbursement of the treatment expenditure and a compensation of Rs25,000 for the mental harassment and litigation costs.

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