Insurer ordered to pay Rs1.6 lakh for repudiating claim

Insurer ordered to pay Rs1.6 lakh for repudiating claim
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First Published: Sun, Jun 17 2007. 12 42 PM IST
Updated: Sun, Jun 17 2007. 12 42 PM IST
PTI
New Delhi: The State Consumer Commission has pulled up an insurance company for denying mediclaim on the ground of “concealment of pre-existing ailment” and asked it to reimburse Rs1.61 lakh to a man who underwent cardiac surgery within days of purchasing the policy.
Terming the act as an example of “unfriendly approach”, the Commission headed by Justice J D Kapoor asked the National Insurance Company Ltd (NICL) to pay the amount, with interest, to the policy holder Raj Narayan in a month.
“Such an approach is not at all consumer friendly but is an approach accentuated and prompted by dubious design as to how to frustrate and reject the claim of consumer...,” the Commission said.
Denying its liability, NICL took refuge under the exclusion clause of the insurance policy which provided that mediclaims can be denied if it is proved the pre-existing disease was not disclosed by the insured at the time of purchasing the policy.
Heart disease is such an ailment which sometimes a person finds difficult to detect at first go, it said, adding “Unless a person is diagnosed and hospitalised for such a disease in the near proximity of obtaining insurance policy, he is not supposed to know as to from which disease he is suffering from”.
To expect a layman to come to the conclusion that he is having a heart disease merely because he feels chest pain or some other pain, was “too much,” the Commission said.
Narayan, a resident of Rohini in north-west Delhi here, was forced to undergo a heart surgery in July 1999 following his sudden illness and was denied reimbursement of Rs1.61 lakh incurred on his treatment.
Narayan, however, had challenged the repudiation of mediclaim, saying he had no history of any heart problem and hence, the stand taken by NICL was “unjustified and unfair”.
Making a strong remark on the structure of the proposal forms that are signed by the consumers in order to accept the terms and conditions of the policy, the Commission observed that no consumer was expected to understand these “micro printed terms running into pages”.
It has directed the NICL to pay Rs1.61 lakh towards reimbursement along with an interest of 10 per cent within a month to Narayan.
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First Published: Sun, Jun 17 2007. 12 42 PM IST
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