Consumer commission pulls up insurance co for refusing to pay health insurance claim

North Consumer Disputes Redressal Commission directs a private insurance company to pay Rs 1 lakh compensation for mental torture, harassment and litigation costs to Parra resident
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Team Herald

PANJIM: The North Goa Consumer Disputes Redressal Commission, Porvorim, has pulled up private insurance company for refusing to pay health insurance claim and directed the company to pay compensation of Rs 1 lakh to the complainant for mental torture, harassment and cost of litigation.

Benedict Paulo D’Souza of Parra, Bardez had availed a health insurance policy from the Cholamandalam MS General Insurance Company India Limited. The policy was a Family Floater Policy which covered the complainant, his wife and his three children for insured of Rs three lakh. He stated that he had renewed the said policy from time to time.

The complainant stated that after his wife underwent a surgery and was discharged from the hospital, he raised a claim for an amount of Rs 97,798 with the insurance company towards the hospital bills paid by him along with all the relevant documents including the medical case papers concerning the hospitalisation and treatment of his wife.

But the company rejected his claim giving reason as under, “On review of the submitted claim documents, it is observed that the insured is suffering from Hypothyroidism since 8-10 years, which is prior to inception of the policy August 22, 2019 and this information is not disclosed in the proposal form while proposing for insurance. In view of this non-disclosure of material information, the contract of insurance becomes void and no claim is payable under this policy clause 4.20.”

North Goa Consumer Disputes Redressal Commission comprising president Bela N Naik, presiding member Aureliano De Oliveira and member Rejitha Rajan observed that if the insurance company was very strict with the insurance policy Clause 4.20 and terms and conditions of the polices, then it should also be strict to carry out a medical test of the policy holders with their registered medical practitioners or their medical clinics before issuing the respective insurance policies to the people in order to ascertain and find out if the said person is having any pre-existing diseases which is not covered under insurance policy.

It is improper on the part of the company to ask the persons to do a self-medical examination and submit the medical report to them and to issue the respective insurance policy on the basis of the said medical report. Therefore, the company cannot say that the complainant had suppressed the material information with regards to the pre-existing health issues. The company had failed to do the medical examination of their own of the complainant and his entire family before insuring them.

Herald Goa
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