The experience of being denied mediclaim insurance after spending a huge amount on medical treatment can be bitter. If one reads the list of diseases that are not covered and diseases which are excluded from coverage — yes, there are two such lists in some companies — one will be in the depths of despair as most of the common diseases are exempted. If one makes a claim for a disease outside the two lists, the usual reason for rejection is that the claimant had a pre-existing disease and that he had suppressed the information. You feel checkmated. But not any longer.
Take a look at this case, for instance. Mr Damani took a medical claim insurance policy cover for Rs 3,50,000 from 09-06-2000 to 08-06-2001 and paid a premium of Rs 5,174. He was subjected to complete medical examination by the doctor of the insurance company. Six months later, he developed chest pain and underwent an angiography, which revealed three blocks in his vessels. His claim for Rs 26,741 was rejected by the insurance company on the ground that he had suppressed information of a pre-existing disease. The district forum and the state commission justified the rejection of the insurance company citing the exclusion clause: “If the symptoms of the disease existed at the time of taking the policy and even if the insured person was not aware of the existence of the symptoms, the insurance company was not liable to pay any claims .”
The national commission, however, did not accept this. It said that if the interpretation of the exclusion clause was to be accepted, the insurance company would not be liable to pay any claims whatsoever, because most people suffer from symptoms of diseases without knowledge of the same. It noted that “this policy is not a policy at all as it is just a contract entered only for the purpose of accepting the premium without the bona fide intention of giving any benefit to the insured under the garb of pre-existing disease. Most of the people are totally unaware of the symptoms of the disease... But common people do not have medical knowledge and cannot diagnose their own diseases. If they were expected to be so aware of their medical condition at all times, there would be no use of insurance policies. Since he was found to be hale and hearty at the time of medical examination by the insurance company’s doctor and since he had no symptoms like chest pain before taking the policy, the question of linking the symptom with the disease does not arise.” The insurance company was asked to pay up. This was a landmark judgment delivered on October 3, 2006.
The Insurance Regulatory and Development Authority (IRDA) stipulates that the insurer or intermediary shall provide all important material or information to the consumer to enable the consumer to decide on the best cover that suits his interest. Such advice must be given dispassionately. The regulations further mandates that the “exclusion clause” must be explained to the consumer before issuing the insurance and, if the company does not explain, it cannot claim the benefits of the exclusion clause. The IRDA has a grievance cell too (irda@irda.gov.in). There is an ombudsman for insurance who can be reached at
insombud@md4.vsnl.net.in. Since this has not been very effective, cases pile up before consumer fora.
Very often, the cover note is passed off as a policy document. The consumer must insist on a policy document which has terms and conditions printed in detail. Ask the agent of the insurer to write down what is included in the coverage and then decide on insurance. The consumer must pay the premium on time and disclose all facts before taking insurance. The “no medical check” offer is not an advantage but a trap. Consumers must insist that the insurance company’s doctor conducts all the tests on the consumer and records his findings in the proposal form. This will help you if the company tries to reject your claim on the basis of “suppressed information”.
