Insurance co declines claim of seizure patient, fined

Ludhiana: The District Consumer Disputes Redressal Commission has ordered an insurance company to pay a composite cost of Rs 5,000 to a man after it declined his reimbursement claim for the treatment of his seizure disorder. The commission comprising its president Sanjeev Batra and members Jaswinder Singh and Monika Bhagat also ordered the company to reimburse the expenses incurred by complainant Karan Mahajan of Durga Puri in Haibowal Kalan during his hospitalisation in DMC Hospital minus the amount of Rs 5,994 refunded to him on February 15, 2020.

Karan had taken a mediclassic insurance policy from the company for the period May 18 2019 to midnight of 17 May 2020 on completion of formalities/proposal form and on payment of premium of Rs 5,994 for the sum insured amount of Rs 5 lakh. The complainant submitted that during the policy period, he was admitted in DMC Hospital on December 28, 2019 with complaint of history of syncopal attack on December 16, 2019, but this time the episode lasted for 10-15 minutes with frothing and clenching of teeth etc. The complainant sent request for cashless facility to the insurance firm, but till the time of his discharge, the firm failed to communicate their decision which compelled the complainant to pay the hospital bill amounting to Rs 24,614. The cashless facility was denied by the firm on December 30, 2019, on the ground that the insured patient has been suffering complex partial seizure and was on treatment from 1998-2003 which is prior to inception of the first policy. Hence it is a pre-existing disease. But the insured had failed to disclose this in proposal form at the time of inception of the first policy and this amounts to concealment of material fact.The opposite parties denied cashless facility as well as claim on this objection and stated that in accordance with condition number 12 of the policy, the policy is also liable to be cancelled and the complainant will receive a separate letter in this regard. The complainant further said the opposite parties never made the above said policy conditions as part of the policy nor communicated the same to the complainant and there was only reference of condition No.4 and there was no reference of other conditions as alleged. The commission said the firm has not referred to any particular document from where such observation has been derived from. “However, assuming it true, the point of consideration arises whether complex partial seizures suffered from 1998 to 2003 amounts to pre-existing disease or not and if not, whether its non-disclosure amounts to violation of any terms and conditions of the policy,” the commission said. It held that perusal of the policy document defines pre-existing disease as any condition, ailment or injury or related condition (s) for which the insured had signs or symptoms and/or were diagnosed and/or received medical advice/treatment within 48 months prior to his first policy with any Indian insurer.“This stipulation clearly indicates that any disease prior to the period of 48 months from the date of its inception does not fall within the definition of pre-existing disease”, the commission held.
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