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PM Modi’s NHAM project will bring about evolution of the health insurance model: Court

The court observed that a person suffering from a genetic disease, is as much in need of a medical insurance cover as others and the liability qua them is more.

By: PTI | New Delhi | Published: May 1, 2016 10:48:32 am
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“Good health is a justiciable fundamental right”, a Delhi court has said while observing that Prime Minister Narendra Modi’s ambitious project for health insurance cover for everyone would bring about an ‘evolution’ in India’s health insurance model.

The court’s observations came while pulling up the United India Insurance Company Ltd, a Public Sector Unit (PSU), for rejecting the mediclaim of a person for heart ailment on the ground of genetic disease exclusion clause.

“I hold that a genetic disease exclusion clause in a mediclaim insurance policy which is a contract between the insurer and the insured and which totally excludes the grant of insurance in case of genetic diseases, is liable to be struck down being violative of the constitutional mandate, the fundamental underlying constitutional scheme, policy of the State and public good.

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“Such clauses are arbitrary, discriminatory and unfair as they discriminate persons suffering from genetic disorders/ diseases from state assistance,” Additional District Judge Kamini Lau said.

The court said, “The ambitious project of Prime Minister Narendra Modi i.e. National Health Assurance Mission (NHAM) envisioning a scheme for health insurance cover for everyone is yet to effectively put in place and rolled out before it can be offered to everyone and this would bring about an evolution of the health insurance model in India as promised.”

The court, while deciding the suit against the insurance firm, said plaintiff Jai Prakash Tayal was entitled to recover from the company Rs five lakh which he had spent for his treatment at the hospital.

The firm had denied mediclaim saying “genetic disease is not payable as per policy genetic exclusion clauses”.

The man had told the court that he has already taken two claims for the same treatment and therefore, a third claim for the same disease was not liable to be rejected.

The court observed that a person suffering from a genetic disease, is as much in need of a medical insurance cover as others and the liability qua them is more.

The court said, “No person can be discriminated or deprived of a State protection in case of an ailment, be it genetic or acquired….the courts of law are required to interpret the provisions of the private contracts in the light of these constitutional obligations.”

The judge added that any failure on the part of service provider/ insurer would be a violation of the existing law and the repeated directions of the Supreme Court for which the
regulatory authority i.e. IRDA would be obligated to intervene to ensure that needful is done by the service provider.

The court also said that a human society must be able to provide basic health access to its citizens irrespective of their paying capacity.

“I may observe that good health is not a privilege but a justiciable fundamental right…

“However, in our country the health care finances have a poor record and only four per cent of the national budget spent on health.

“An alternative which has largely remained unexploited is providing health coverage via health insurance where the government rather than necessarily running its own health facilities is required to consider the alternative of providing health insurance to its citizens and time has come that India catches up with this alternative model of allocating resources and funding to its public health programs,” the judge said.


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