Case Study 19 - HC powers consumer’s mediclaim

The Delhi State Consumer Commission has directed an insurance company to pay medical expenses incurred by a patient within a year of taking a mediclaim policy even though the exclusion clause stated otherwise.
The Commission noted that the insurance company was guilty of not bringing the exclusion clause to the notice of the policy holder while issuing the policy.
The exclusion clause stated that no medical reimbursement would be provided to a policyholder if he suffers from a disease within a year of taking it.
"There is no mention of internal congenital disease like ASD disorder from which the complainant suffered and for which he was operated upon. We find no infirmity in the impugned order (of the District Forum) because exclusion clause was not brought to the notice of the complainant and, hence it cannot bind him," the Commission said.
The policy was obtained in 2003 from United India Insurance Company Limited. Within one year, the complainant underwent an operation for Arterial Septic Disease (ASD) following which he applied for reimbursement which was rejected by the company.
While rejecting the company's contention, the Commission relied on the lower forum's observation which said that the complainant's discharge summary proved that he did not have any symptoms of the disease from two months prior to the date of operation.
"Policy was obtained on March 3, 2003 and the complainant was admitted in the hospital on November 4, 2003 with complaints of palpitation and breathlessness only," the Commission bench headed by Justice B A Zaidi said.
After his medi-claim was rejected by the company, the policyholder, Sushil Kumar, approached the Delhi District Forum which directed it to pay Rs one lakh towards insured amount besides Rs 10,000 as compensation.

Source - financialexpress.com