Ten years after an insurance company denied a man’s claim for the reimbursement of the expenses of his wife’s surgery, a consumer court in Delhi recently directed the firm to pay him Rs 4 lakh. The denial of the claim was “arbitrary”, the court observed, adding that the man suffered “financial loss, and mental agony” due to the refusal. ".this Commission is of the view that denial of the claim of the complainant by the OP (New India Insurance Company Limited) is arbitrary, without any valid ground and contrary to terms and conditions of the policy and amounts to deficiency of services on its part because of which the complainant has suffered financial loss, physical trauma, harassment and mental agony and is entitled to the relief claimed," said the District Consumer Dispute Redressal Commission (central district), in an order dated July 10. Nishchal Jain, the complainant, had taken a mediclaim policy for his family from the insurance firm in 2005. He said he constantly renewed the policy by paying regular premiums. The insurance company had promised Jain a "cashless facility" in all major hospitals, he said. His wife was admitted to Fortis Hospital in Gurgaon for a surgical procedure in August 2014. However, the insurance company did not approve the cashless facility and Jain ended up paying Rs 5 lakh for the surgery, he said. Four months later, in December, Jain filed a complaint with the Grievance Redressal Committee of the company. The complaint was, however, declined in January 2015, according to him. The insurance company stated that the policy applicable in the case was of the year 2010-11, which restricted the insurance sum to Rs 3 lakh. The policy that Jain insured him for sums up to ₹8 lakh. Clause 4.1 of the policy — which dealt with pre-existing diseases — was cited by the company. “It is a medical condition/disease that existed before you obtained a health insurance policy, and it is significant because the insurance companies do not cover such pre-existing conditions, within 48 months prior to the first policy. It means pre-existing conditions can be considered for payment after completion of 48 months of continuous insurance cover,” it read. The insurance company said that Jain’s wife was admitted with a pre-existing disease, which is covered only after four consecutive claims. However, siding with Jain, the commission observed that as per Clause 4.1 of the policy, the exclusion clause is applicable from the inception of the policy (2005) till 2009 only. “The documents on record show that the complainant has taken the policy from OP for the first time in the year 2005 which fact is admitted by OP, therefore, as per the exclusion clause, four years shall start from 2005 and end in 2009, and thereafter, the exclusion clause shall have no applicability upon the policy of the complainant and he will be eligible for the 100% claim or sum insured under the policy," the commission noted. The commission also said that since Jain's wife was admitted in 2014, the claim has to be dealt with with the policy applicable from 2014 to 2015 that assured a sum of ₹8 lakh to Jain and his family.
