United India Ordered To Pay Mediclaim: Pre Existing Disease

Deciding on a case filed by Consumer Education and Research Society (CERS), Ahmedabad, and Ranjanben V. Soni, Ahmedabad, the Consumer Disputes Redressal Forum (CDRF), Ahmedabad City (Additional), found United India Insurance Company guilty of deficiency in service.

The Forum allowed the complaint and ordered the insurer to pay Ranjanben V. Soni within eight weeks from 18 August 2009 (the date of order) Rs. 5,173 and Rs.16, 708 along with 6 per cent interest from the date of repudiation i.e. 24 July and 5 June 2002 respectively, till the date of payment.

Ranjanben and her husband Vinaychandra Soni had taken a yearly Mediclaim policy of Rs. 50,000 with United India Insurance Company. They renewed the annual policy for four years to be valid up to 30 March 2003, paying a premium of Rs. 1,564. On 27 February 2002, she was admitted to the Parth Medical Nursing Home, Ahmedabad for urine infection and was discharged on 2 March 2002. The cost of treatment was Rs. 5173.55.

She requested United India for reimbursement on 2 April 2002. The insurers repudiated the claim on the basis of “a pre-existing disease”. She contended that she had never had such an infection and requested the insurers to reconsider her case. Meanwhile, on 3 May 2002, she was admitted to SAL Hospital, Ahmedabad for some cardiac problem and, after treatment, was discharged on 9 May. She applied again, along with documents, to United for reimbursement of Rs. 16,708. United repudiated this too on the basis of “a pre-existing disease”. Ranjanben approached CERS and together they filed a complaint with the Forum, alleging the repudiation of policy on wrong grounds and deficiency in service.

United India contended that on receiving the application for reimbursement, it had investigated the case and collected information from Ranjanben’s doctor that she had been suffering from cardiac ailment for long. Hence the repudiation of the claim was not baseless.

Meanwhile, Ranjanben died on 16 May 2008. Her husband Vinaychandra Soni pursued the case.

The Forum passed a verdict in favour of Rajanben. It held that the burden to prove that the disease was pre-existing is on the insurer for which, in this case, there was no proof except for the oral information collected by the insurer from the doctor. The Forum also noted that the insurer could not prove that the disease pre-existed or existed in 1997.

The Forum comprised Mr. V.C. Modi, president, and Mrs. J.Y. Shukla, member.