Disease not known by insured cannot be treated as Pre Existing

If any disease is not diagnosed specifically it cannot be treated as Pre Existing Disease. Insurance Company ordered to pay the claim. 


Ahmedabad Ombudsman Centre
Case No. NIA / 1 / 298
Smt. Abha N. Shah
The New India Assurance Company Ltd.
Award Dated 11.10.2004

Complainant’s 9 years old daughter underwent Appendectomy. Claim repudiated on the grounds of pre – existence of disease. Complainant submitted that due to severe abdominal pain, they consulted their family Physician who referred the case to Dr. A. P. Munshi.

Dr. Munshi diagnosed the disease as Appendicitis and advised operation. Respondent submitted that according to their MR, who obtained a statement from the Complainant, the Insured was having the disease for last 2 years, and hence the disease existed prior to the inception of the Cover.

During hearing, the Complainant submitted that she does not know the meaning of “Conservative treatment”, and explained that the MR of the Respondent Dr. Y. C. Shah asked her whether the child had pain in the stomach ever and she recalled 2 years back there was some such pain and for that she consulted Dr. Desai who prescribed medicines and cured the pain. Documents and submissions perused.

Explanation of the Complainant found convincing though she had signed the statement. Eventhough Dr. Desai’s Chamber was very near to the house of the Complainant, Dr. Shah chose not to visit Dr. Desai and get clarification from him. It is also opined that a disease of potential danger to the life of a child was allowed for 2 years through conservative treatments is a difficult position of reconcile.

Weightage has been given to Dr. Desai’s certificate produced by the Complainant during hearing. Repudiation set said.

Respondent to pay Rs.19088/- as FFS to the Complainant.

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