September 19, 2021 4:13:15 am
The State Consumer Disputes Redressal Commission has directed an insurance firm to pay Rs 3.76 lakh to a Himachal Pradesh resident for rejecting his medical claim for treatment of cancer availed abroad.
Charanjeet Singh, 61, alleged that he purchased a medical coverage insurance policy Religare Health Insurance, effective for the period from August 14, 2018 to November 30, 2018, for sum insured as USD $50000, and the policy was issued at Chandigarh.
The complainant developed health problem while he was abroad and was hospitalised at Alfred Health Hospital in Melbourne on October 1, 2018 and discharged on October 4, 2018. It was stated that as per pre-insurance form and policy certificate, the complainant also provided additional details regarding his previous illness, treatment and injury during the last 48 months, which is that he got “treated for cancer in 2017”.
However, the claim of the complainant was rejected by the insurance firm on March 22, 2019 under a clause of the policy that any claim in respect of any insured person arising directly or indirectly due to Oncology (Cancer disease) will not be admissible under the policy. As his claim was rejected, Singh filed a complaint at the Chandigarh Consumer Forum.
In reply, Religare Health Insurance submitted that the policy of insurance is the evidence of the terms of the agreement between the insured and insurer and the promise of the insurer to indemnify the assured is subject to the terms and conditions and exceptions of the policy. It was further stated that the complainant was directed to submit necessary documents and as per the claim form signed by the hospital, it was duly mentioned that the current ailment of the complainant is a complication arisen from the previous treatment. The insurance firm consulted an expert who opined that the ailment was a known complication of medical condition Laryngeal cancer and thyroidectomy for which the complainant was under treatment prior to the policy inception.
The Commission bench, after minutely going through the documentary evidence available on record, held that there is nothing on record to show that whether the policy terms and conditions, which the opposite parties have placed on record as, were ever supplied to the complainant and in case, the same were supplied, what was the mode and manner, in which, the same were supplied.
“The opposite parties had given this note in very minute and small letters and by giving such a note, they tried to evade their part of responsibility of providing the accompanying terms and conditions of the policy in the hands of the consumer (complainant herein). In our opinion, prime duty, which casts upon the Insurer is to inform and make understand each and every term and conditions of the Policy to the insured at the time of subscribing or providing the policy. In the absence of such terms and conditions, the consumer cannot be taken by surprise by saying that the claim is not covered under exclusion clause,” said the Commission bench.
The State Consumer Disputes Redressal Commission, thus, directed the insurance firm to pay the sum insured of Rs 3,76,848 to the complainant, along with interest at 9 per cent per annum (simple), from the date of rejection of the claim, which is March 22, 2019.
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