The District Consumer Disputes Redressal Commission, Ahmedabad (Additional), has held The Oriental Insurance Company Limited guilty of ‘deficiency in service’ for illegally repudiating a mediclaim on the ground of alleged pre-existing disease.
Allowing the complaint partly, the Commission has directed the insurer to pay Rs 5 lakh (sum insured) with 7 per cent interest, along with compensation and litigation costs. The case pertained to the husband of the complainant who was hospitalised for the treatment of palpitation in a private hospital in 2018 and subsequent ailments from 2019.
The order in the case of complaint filed on behalf of wife of the insured by the Consumer Education and Research Centre (CERC) — a not for profit organisation working for consumer protection and empowerment — on December 24, the Commission observed that the insurer failed to prove suppression of material facts regarding hypertension, which was cited as a pre-existing disease to deny the claim.
“Relying on medical records and the treating doctor’s certificate, the Commission noted that mere reference to hypertension — commonly a lifestyle disease — without establishing a nexus with the hospitalisation cannot justify repudiation,” said Anusha Iyer, deputy general manager, CERC.
The Commission also rejected the insurer’s objection on limitation, holding that the complaint was within time in view of the Supreme Court’s suo motu orders extending limitation during the Covid-19 period.
“The judgment reinforces that insurers must strictly prove non-disclosure of pre-existing diseases and cannot repudiate claims mechanically, thereby strengthening consumer protection in health insurance matters,” she further added.
‘…it is also relevant to consider that, as per certificate of the treating doctor has been produced on record for the complainant side, wherein it has been specifically mentioned that, “No history of D M, HTN since 2O14 and Underlying Cause of present ailment : Not known…..On the contrary neither the explanation was asked to the treating doctor nor any adverse as well as expert opinion has been presented for the lnsurance Company on record’ simultaneously it is also relevant to consider that, at the time of the policy the age of the insured was 75 years, yet no facts regardlng the medical examination has been produced on record. Therefore due to lack of such cogent facts on record the commission declines to agree with the contentions for the Opponent Insurance company’ the order stated.
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The Commission also considered the ‘relevancy of the case of Bajaj Allianz General Insurance Co. Limited V/s Valsa Jose lV 2012’ of the National Commission that, “Hypertension is usually a lifestyle disease and easily controlled with conservative medicine .”