New Delhi District consumer disputes redressal forum, in its order has held that for medical insurance claim settlement, disease can not be said to be pre-existing unless it has been certified so by a doctor on the basis of medical test prior to the purchase of the policy.
This order has come on the plea of Delhi resident Padam Sain Dhingra, who had alleged that National Insurance Company Ltd has arbitrarily rejected his claim of Rs 50,000 incurred by him on his wife’s treatment.
Dhingra’s wife was admitted in Max Balaji hospital on complaint of breathlessness on 23 December 2008 and discharged on 22 January 2009.
Insurance company rejected his claim citing that his wife was suffering from heart problem since 2005 and policy was bought in 2006.
However, forum was not agreed with the company’s argument, it said that it did not have any direct positive evidence of any known sickness of insured, except observation of doctors, made in discharge summary.
Forum observed that doctor in its discharge summary recorded that the patient suffered from heart problem since 2005 on the basis of inference or talks. And on the basis of mere talks, disease can not be said to be pre-existing. If a doctor on talking with a patient gives a particular name to a condition explained by patient, it is not sufficient as a positive evidence of pre-existing disease for purpose of insurance.
Citing that company rejected claim arbitrarily, forum directed insurance company to pay Rs 50,000 as claim to Dhingra and Rs 25,000 as compensation for causing harassment and litigation expenses.
Categories: News | Tags: Health Insurance, Pre-existing Disease
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