Case Study 34 - Pre-existing disease at the time of taking the health insurance

Mr. Devinderpal Singh, a resident of Jamalpur, had taken a Mediclaim policy from the company for his 10-year-old son Raja. He was insured for Rs 20,000 for the period from October 13, 1998 to October 12, 1999. The complainant stated before the forum that in the first week of November, 1998, his son, felt severe pain in his abdomen. After the medical examination, a stone was found in his kidney. Thereafter, Raja was taken to the Sidhu Hospital for the treatment and there he underwent treatment in November 1998. The complainant stated that he had spent huge amount on his treatment but could not preserve all the bills and submitted the bills for Rs 18,500.

The company pleaded that the said policy was obtained after concealment of the precious disease as the disease was pre-existing at the time of taking the policy as such the claim was not payable. The company further stated that Dr Tarsem Lal Gupta who was referred the case for the medical opinion, said Raja was suffering from pre-existing disease at the time of taking the insurance policy and as the claim fell within the exclusion clause No. 401 of the policy. The company maintained that the claim was rightly repudiated.

The forum observed, "It appears as if the father of Raja had knowledge of the disease and as such he took the policy to meet the expenses of the treatment. The forum stated that the disease was pre-existing and was not covered under the policy. The forum further added that the company had intimated the complainant that the claim lodged was considered as 'no claim' as per the rules of the policy. The forum held that there was a clear deficiency on the part of the company for not intimating the complainant. CDRF asks OIC to make full payment of Mediclaim.