Nov 17
From time to time, we come across cases where an insurance company will deny medical insurance to a person desperately needing the insurance; and why do they do so ? Well, obviously for an insurance company, the less claims that they can pay out, the more their profits. And in the case of medical insurance, using an excuse such as diabetes or hyper-tension gives an easy way to avoid making the insurance payment. If the concerned patient has either of these 2 modern diseases (that are very prevalent), then the insurance company can claim that these are pre-existing diseases and hence the claim can be rejected. This gambit must have succeeded in a number of cases, till this gentleman filed a case in the consumer forum against the insurance company and the consumer court rejected the contention of the insurance company:
The National Consumer Disputes Redressal Commission has ruled that the claim for a particular ailment cannot be rejected merely because the insured person is suffering from some other disease, say for instance, diabetes. Diabetes and hypertension are two of the standard dodges used by insurance companies to reject claims.
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Nov 07
If you have ever read the agreement for insurance, there will be a number of items in fine print, including exceptions. So, for example, if you are taking insurance for your car or other vehicle, the Insurance company would have added exceptions to the order of driving the vehicle illegally, or using it for racing, or for a unqualified person to be driving the vehicle. Such clauses could also mean that if you need a certificate from the transport department for driving the vehicle, and don’t have the certificate, an insurance company could claim that you are violating the law while using the vehicle, and hence there is no ground for insurance. This particular attempt to use the law violation to deny the claim has been struck down by the Chennai Consumer Commission as being used to deny justice to the consumer.
The National Consumer Commission has held that insurance companies, if the terms of the policy were not breached, cannot refuse to entertain claims on the pretext that the insured violated some other laws or conditions.
It was deciding a petition filed against the Chennai State Consumer Commission verdict, justifying the repudiation of an accident claim by the United India Insurance Company Ltd on the ground that the car, at the time of accident, was being plied without the ‘fitness certificate’ as required under the Motor Vehicle Act.
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Oct 16
With medical costs increasing nowadays to a large degree and with specialized treatment becoming much more expensive, having medical insurance is absolutely necessary. Not having medical insurance means that you can be in a tremendous financial problem when the need arises to avail of medical services. However, it gets problematic when the insurance company uses any means to avoid paying the insurance claim. In such cases, it is the consumer redressal forums that intervene and get the insurance company to pay the claims:
NEW DELHI: The State Consumer Commission has rebuked three public insurance companies for wrongly repudiating the ‘mediclaim policy’ and insurance claims against ‘life-policy’ in four different cases on grounds of concealment of pre-existing ailments. The companies - namely Life Insurance Corporation of India, Oriental Insurance Company and New India Assurance Company - were pulled up by the city’s apex consumer commission for rejecting, ‘on highly flimsy grounds’, legitimate claims made by consumers.
The insurance companies have been directed to pay lakhs in compensation for the wrongful rejection of the claims made under various policies.
Justice Kapoor clearly noted that “Malaise of hypertension,diabetes, occasional pain, cold, headache, arthritis and the likes in the body are the wear and tear of modern day life which is full of tension at the work place … These cannot be used as concealment of pre-existing disease for repudiation of an insurance claim, unless an insured in the near proximity of taking of the policy is hospitalised or operated upon for treatment of these diseases or any other disease.’’
This judgment will be useful for all mediclaim users, given that at the times of emergency when there is a need for money, there should not be the fear that the claim will be rejected for some reason or the other.
