The Chandigarh Consumer Forum directed an insurance firm to pay Rs 2.09 lakh to a Panchkula woman, for rejecting her claim for the treatment of cancer.
Bimla Devi of Panchkula obtained a medi-claim policy from IFFCO-TOKIO General Insurance, for herself from October 16, 2017 to October 15, 2018 and got it renewed further uptil October 2019.
Devi said, in September 2018, she encountered post menstrual bleeding for four to five months, and eventually went for laboratory examination of endometrial biopsy and cervical biopsy. She then approached Cloudnine Hospital, where, as per advice of the doctor, MRI was done and CA Endometrum was diagnosed.
The doctors said that Bimla Devi was suffering from post menopausal bleeding PV, CA Endometrium stage 2 with known case of hypertension for Laparoscopic Radical Hysterectomy. Devi said, she was advised to undergo a surgery for the treatment of Endometrial cancer and she underwent the same on October 24, 2018 at Cloudnine Hospital. After the surgery, her samples were sent for laboratory examination and from a report of November 1, 2018, it was found that the complainant was suffering from cancer stage-1.
Devi said that after the surgery and discharge, she submitted her claim form of expenditure incurred on the treatment to the tune of Rs 1,99,980 to the insurance company for reimbursement. However, it was rejected on the grounds that the condition of the complainant was pre-existing at the time of signing the policy. She thus filed a formal complaint at the Consumer Forum of Chandigarh in February 2019.
The IFFCO-TOKIO General Insurance company, in its reply, said that it has been revealed from her treatment record that the complainant already suffered from Dysfunctional Uterine Bleeding since 2009 and underwent Diagnostic and Therapeutic D & C in 2009.
Further, she underwent menopause in 2010, with amenorrhoea for 8-10 months and then had post menopausal bleeding, following which her USG report showed uterine myoma. The USG done in 2010 showed a bulky uterus with coarse myometrum, and discharge summary of the complainant for her admission in hospital on October 24, 2018 revealed that she was hypertensive for three years and was on regular medication. It said that since the condition of the complainant is pre-existing and was not disclosed at the time of obtaining the policy, the claim of the complainant was not admissible.
After hearing the arguments, the forum held that, it was not only well proven on record, rather has also been admitted by the insurance firm that the complainant had her Menopause in 2010, a natural phenomena that females undergo at a certain age and its complication, if any, is curative by particular procedures. In the present case also, the complainant underwent post menstrual bleeding and got treatment for the same.
The forum further held that the plea of the insurance firm that the complainant had knowledge of her disease earlier to the issuance of the policy, is absolutely wrong, as it is not expected that one would prefer to not be treated for years together. Had she been aware of her present ailment, Endometrial cancer, in the year 2010, when she get treatment for menopause problem, she would not have waited till 2018, just in order to get a medical claim.
Referring to the judgement of the National Consumer Disputes Redressal Commission, New Delhi, in 2013 Revision Petition of Satish Chander Madan vs Bajaj Allianz General Insurance Co Ltd, which held that “Hypertension is a common ailment and it can be controlled by medication – Claim was wrongly repudiated”, the Chandigarh Consumer Forum bench found the claim wrongly rejected and directed the insurance firm to reimburse
Rs 1,99,980 to the woman with interest at 9 per cent from the date of the rejection, along with Rs 10,000 as compensation.