Health Insurance Firm Asked To Pay Rupees 3 Lakh To Claimant

Thane: A consumer court here has ordered a health insurance company to pay Rs 3 lakhs to a claimant as it failed to prove that his wife was suffering from a disease prior to issuance of the policy.

Complainant Dilip Mohite informed the Thane District Consumer Redressal Forum that he had taken a floater insurance for Rs 3 lakhs for his family members, including wife and two children, from Star Health and Allied Insurance Company.

In June 2012, his wife fell ill and had to undergo an angiography and angioplasty, for which he had lodged a claim of Rs 3 lakh with the insurance company.

However, the insurance firm rejected the claim stating that it was a pre-existing disease which Mr Mohite had concealed at the time of taking the policy, and thus rejected it. Mr Mohite then approached the forum seeking a claim of Rs 3 lakh and Rs 50,000 as compensation.

The insurance firm said it was observed that there were 90 per cent blockages (in heart) detected on the patient, which meant that it had taken a long time to develop and can be treated as pre-existing, and hence it rejected the claim.

Forum president Shena Mhatre and members Madhuri Vishwarupe and ND Kadam gave the definition provided by a court ruling in a case that "pre-existing disease is one for which the insured should have undergone hospitalisation or undergone long treatment or operation."

The insurance firm had not produced any proof of the claimant undergoing any treatment of heart ailment prior to the present illness, and hence the contention that the disease was pre-existing cannot be accepted, the forum noted.

As there is no proof whatsoever of the claimant having been treated or admitted for any heart ailment prior to the taking of the policy, the reasons given by the insurance company cannot be accepted, it observed.

Thus, the forum last week ordered the insurance company to settle the entire claim amount of Rs 3 lakh to the complainant along with a compensation of Rs 10,000.