NewsDesk
29-09-2011, 02:18 PM
The State Consumer Disputes Redressal Commission (SCDRC) has directed ICICI Lombard General Insurance Company to pay N Somasundaram Rs 48,604 towards his medical reimbursement claim, with costs of Rs 3,000.
According to Somasundaram's complaint, he had purchased a mediclaim policy from the company for himself and his daughter by paying a premium of Rs 9,357. It was to cover the period from March 17, 2005 to March 16, 2006.
Though he did not have any previous disease while taking the policy, he developed giddiness and chest pain with sweating on November 25, 2005. On his doctor's advice , Somasundaram was admitted to a private hospital for four days that month and for two more days in December 2005. Since angiography was conducted, the medical expenses for both visits came to Rs 48,607.
However, when the claim was made, it was rejected on the grounds that the petitioner was suffering from hypertension for the past 25 years and that he had suppressed the 'pre-existing disease' .
Pointing out that it was unclear how the insurance company had concluded that Somasundaram was suffering from hypertension for the last 25 years, the bench noted that it was the norm for insurance companies to accept the proposal for a policy after conducting a medical examination to check for pre-existing disease.
Neither the medical reports nor the proposal form was produced by the insurance firm, the bench said. Also , the firm had relied on the statement of Dr Jasmine, who examined the petitioner at the hospital, to arrive at a conclusion about his medical history.
The SCDRC bench also pointed out that it was not this doctor who had treated the petitioner earlier nor was he examined by any doctor attached to the insurance company .
The bench said the firm did not produce any proof or medical evidence to arrive at a substantial basis to repudiate the claim.
The insurance company was directed to pay Rs 48,604 towards the medical reimbursement claim with 12% interest from the date of the claim till realisation. They were also directed to pay costs of Rs 3,000 for causing the petitioner monetary loss and mental agony.
According to Somasundaram's complaint, he had purchased a mediclaim policy from the company for himself and his daughter by paying a premium of Rs 9,357. It was to cover the period from March 17, 2005 to March 16, 2006.
Though he did not have any previous disease while taking the policy, he developed giddiness and chest pain with sweating on November 25, 2005. On his doctor's advice , Somasundaram was admitted to a private hospital for four days that month and for two more days in December 2005. Since angiography was conducted, the medical expenses for both visits came to Rs 48,607.
However, when the claim was made, it was rejected on the grounds that the petitioner was suffering from hypertension for the past 25 years and that he had suppressed the 'pre-existing disease' .
Pointing out that it was unclear how the insurance company had concluded that Somasundaram was suffering from hypertension for the last 25 years, the bench noted that it was the norm for insurance companies to accept the proposal for a policy after conducting a medical examination to check for pre-existing disease.
Neither the medical reports nor the proposal form was produced by the insurance firm, the bench said. Also , the firm had relied on the statement of Dr Jasmine, who examined the petitioner at the hospital, to arrive at a conclusion about his medical history.
The SCDRC bench also pointed out that it was not this doctor who had treated the petitioner earlier nor was he examined by any doctor attached to the insurance company .
The bench said the firm did not produce any proof or medical evidence to arrive at a substantial basis to repudiate the claim.
The insurance company was directed to pay Rs 48,604 towards the medical reimbursement claim with 12% interest from the date of the claim till realisation. They were also directed to pay costs of Rs 3,000 for causing the petitioner monetary loss and mental agony.