Insurance Company fined after rejecting medical claim
Max Bupa Heath Insurance company was instructed to pay almost Rs 79 Thousand after it rejected the claim of one of its customers by the district consumer redressal forum. The company which is in Chandigarh was instructed to pay Rs 25,000 as compensation and Rs 54,000 along with 9% interest per annum after it rejected the medical claim of one Sanjeev Kumar Nagrath, a Sector 45 resident.
The complainant, Sanjeev Kumar Nagrath said that while replacing the handle cover of a cricket bat of a customer in the first week of March 2017, he developed pain in his abdomen. He got himself checked in the same week itself at the government hospital and was diagnosed with par umbilical hernia and was advised to go under surgery which was conducted under general anaesthesia. He remained admitted in the hospital for the next two days after his surgery. The told amount for his surgery came down to Rs 54,648.
When Nagrath submitted his claim to Max Bupa Insurance company, the company rejected his claim stating that he had concealed the disease as he was suffering from umbilical swelling for the past six to eight months. When the matter went to the forum, the company in its reply stated that since the complainant had been suffering from the disease for the last six to eight months and the fact that he had concealed this information, his case fell into the exclusion clause and the claim was therefore rightfully rejected. An important note made by the forum was that the symptoms of the disease were felt in March of 2017, after the complainant had taken the policy.
Also, a simple swelling the umbilical cord cannot be taken as a diagnosis for hernia or a disease which required surgical treatment. The company was unable to prove on record that on the date of issuing of the policy which is February 24, 2017, that the complainant was suffering from par umbilical hernia which required surgery and treatment. There was only a mention of umbilical swelling in the complainant’s medical records. The forum further stated that if the insurance company had any doubt regarding the disease, they had the option of getting the complainant medically examined in order to detect the pre-existing disease.
Also, when the forum consulted with the doctor, they were informed that certain chemical reactions in the body are per se not perceptible unless some signs or symptoms appear and are reliably diagnosed by the doctor. Therefore, there was no way of knowing that the complainant was suffering from par umbilical hernia unless a medical test was conducted and there was no reason for the complainant to be concerned with this as he was only aware of swelling in his umbilical cord which is not a diagnosis for a hernia or a disease.
The insurance company was therefore directed by the district forum to not only pay the amount which was spent on medical treatment but was also directed to pay additional amount as compensation.
For case specific advice related to your rejection of insurance claim, one can contact Top/Best Expert Consumer Court lawyer of Chandigarh Panchkula Mohali.
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