Forum Makes United India Pay Mediclaim: Pre Existing Disease

The Consumer Disputes Redressal Forum, Ahmedabad (Rural), has partly allowed a complaint filed jointly by Consumer Education and Research Society (CERS), Ahmedabad, and Mrs. Reshma Trivedi, holding United India Insurance Company Ltd. liable for negligence and deficiency in service.

The Forum has ordered the company to pay Reshma Rs. 30,000 towards her mediclaim policy with 9 per cent compound interest from the date of complaint till realisation and Rs. 5,000 towards cost.

Reshma had taken a mediclaim policy of United India Insurance Company Ltd. on 27 October 2000, and renewed it in 2001 till 27 October 2002.

Reshma had undergone a hernia operation for the second time in May 2002, for which she filed a claim of Rs. 27,500 on 10 May 2002. The company rejected her claim saying that the ailment (hernia) was present when she had applied for the policy. The company, after consulting its panel doctor, had reasoned that Reshma had undergone caesarean and hysterectomy operations, due to which she suffered from hernia for the first time and subsequently for the second time too. The hernia, she was operated for, was existing while she took the mediclaim and had not specified the information under the pre-existing clause. United India Insurance, therefore, took the stand that in her case hernia was a pre-existing disease and, therefore, the exclusion clause was applicable.

The National Commission, in the case of Pravin Damani v/s Oriental Insurance, had stated that “Only on the basis of assumptions and experience of a doctor, who had not seen, examined or treated the patient, the insurance company stands no authority to reject a claim”.

CERS contended that it was the responsibility of the insurance company to prove that in Reshma’s case hernia was a pre-existing disease and that the occurrence of hernia had in no way any relation with her hysterectomy and Caesarean operations.

The Verdict
The Forum partly allowed the complaint and directed United India Insurance to pay Reshma Rs. 30,000 of the mediclaim policy with 9 per cent compound interest from the date of complaint till realisation. United India Insurance was also directed to pay Rs. 5,000 towards cost to her.

The Forum comprised Mr. P. U. Rana, President, Ms. Nandini Thakar, Member and Ms. Jyoti Jani, Member