Company must pay for kidney treatment claim at Mohali Hospital: The Tribune India

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Tribune press service

Chandigarh, May 20

Occasional treatment for hypertension (high blood pressure) cannot be conclusive grounds for saying that the patient had a serious pre-existing condition. Observing this, the District Consumer Disputes Redressal Commission, Chandigarh ordered an insurance company to pay a claim of Rs 1,61,181 to a woman for her kidney treatment which was denied on the grounds of concealing previous ailments.

The commission also ordered the company to pay the complainant 15,000 rupees as compensation for causing the harassment, as well as legal costs of 10,000 rupees.

Rajeev Gupta of Ambala had approached the commission after the company refused to reimburse his wife’s treatment claim. In the complaint, Gupta said he and his wife Nisha Gupta obtained a health insurance policy from M/s. Manipal Cigna TTK Pro health insurance. His wife, Nisha Gupta was admitted to Mayo Health Care Super Specialty Hospital, Mohali on February 13, 2020, with kidney problem and she was discharged on February 17, 2020.

He said he showed the police document to the hospital to claim the medical bills but the company refused to make any payment to the hospital, as such the plaintiff had to pay the medical bills of Rs 1 ,61,181 out of his own pocket. He said the company dismissed the medical claim saying that Nisha suffered from certain existing medical conditions and also remained hospitalized, but it did not disclose all of this when offering the policy.

After hearing arguments, the commission said that the mere fact of visiting or consulting a hospital or the PGIMER, Chandigarh, regarding a medical problem/condition does not prove that the person already has a pre-existing serious illness. In addition, when selling the policy to potential customers, the insurance company, in accordance with its rules and procedures, has an obligation to ensure that the purchaser of the policy is in good health in order to be able to purchase the police.

In this case, the company sold the policy to the plaintiff and subsequently repudiated the benefit of the policy citing pre-existing illness/disease. Occasional treatment of hypertension or high blood pressure cannot be conclusive grounds for saying that the patient had a serious pre-existing condition. More so, hypertension is a common disease, which can be controlled by medication.

The company has failed to prove by concrete documentary evidence that the claimant/insured already suffered from a serious illness before taking out the policy in question. Therefore, the company’s act of denying the complainant’s genuine request amounts to a lack of service, which not only caused the complainant enormous financial loss, but also caused him immense harassment and mental agony.

Which panel observed

“Occasional treatment of hypertension (high blood pressure) cannot be a conclusive ground for denying a claim,” says the District Consumer Dispute Settlement Commission, Chandigarh.

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