Diabetes, BP can’t be cited to reject claim

Mumbai: In another blow to a medical insurer hell-bent on rejecting a policy holder’s claims, a district consumer forum has decreed that a cardiac patient cannot be denied his insurance even if he has not mentioned hypertension and diabetes as pre-existing ailments.

‘‘We have taken the view that, in a large number of cases, diseases like hypertension and diabetes are so common and are always controllable... (so) unless a patient undergoes a long treatment, including hospitalization and undergoes operation in the near proximity of taking the policy (sic), (s/he) cannot be accused of concealment of facts,’’ the forum said, while asking the insurer to honour the policy holder’s insurance claims and also pay him Rs 5,000 as compensation for mental agony.
In 2003, Mulund-based Karunakar Shetty underwent a ‘‘coronary artery bypass grafting’’ surgery and ran up a bill of Rs 2,53,553. On July 17, 2003, he intimated Oriental Insurance Company Ltd Co and Raksha TPA. Shetty had taken a policy in 2000 for Rs 3 lakh but, while renewing it in 2002 and 2003, the amount was reduced to Rs 1.5 lakh.In November 2003, Raksha TPA informed him that his claim was rejected as he was suffering from hypertension even before he took the policy and hid this from the insurance company. Shetty, however, contended that he did not suffer from hypertension before he took the policy and even sent a statement from his family doctor to the insurance company. But they did not reconsider their decision, prompting him to file a complaint in the forum citing deficiency in service.
The insurance company denied the allegations and said that in 2003, while renewing the policy, Shetty mentioned that he did not suffer from any pre-existing disease. It even stated that, when the papers were submitted, the third-party authority got documents from a hospital that said Shetty had told them he was suffering from diabetes for the past four years.The insurance company alleged that the statement submitted by the family doctor was false and argued that the heart ailment that Shetty suffered from was closely related to diabetes and this was not covered by the policy.The forum, while passing its order took into account, the hospital discharge card that Shetty had submitted following his treatment in July 2002. From the discharge card and the report submitted by the family doctor it was evident that Shetty was suffering from hypertension and diabetes and he got to know of it only in 2002. The forum observed that Shetty was unaware of the disease when he took the policy in 2000 and, even if he did not mention it in 2003 while renewing the policy, hypertension and diabetes could not be called ‘‘pre-existing diseases.’’