CONSUMER PROTECTION ACT BIG WIN FOR HEALTH INSURANCE CLAIMANTS

New Delhi: In a stern warning to insurance companies and doctors on their panels, a consumer court has ruled that medical policy claims cannot be rejected on flimsy grounds such as non-disclosure of pre-existing diseases. The State Consumer Commission gave this direction while awarding a Rs. 2 lakh compensation to a woman with a hip ailment whose claim was denied by an insurance firm. "We advise doctors on the panel of insurance companies to first equip themselves with basic knowledge (about the case in question)…before giving their opinion, instead of toeing the line of their masters to remain on the panel", said State Consumer Commission president J. D. Kapoor and member Rumnita Mittal.

Issuing directions to insurance companies not to harass policy holders on issues relating to previous treatment of a particular ailment, the commission said. :In our view, the consumer is not entitled to any claim only if he conceals the factum of his hospitalization for a particular disease or having undergone operation for the disease in the near past."

Awarding a compensation of Rs.2 lakh to Sri Chand Jain, the commission said it had come across cases where consumer claims were denied for not having disclosed even minor physical problems that the insured had been facing for decades without it affecting day-to-day life or ever necessitating hospitalization. In a stern warning to insurance companies and the doctors on their panel, a consumer court has asked such firms against rejecting claims on flimsy grounds.

Justice J. D. Kapoor and Rumnita Mittal said insurance companies were repudiating claims citing diseases that can easily be detected through basic tests performed at the time of filing the policy proposal. Insurance companies cannot be allowed to dupe consumers due to their own negligence in performing their obligations like getting prospective clients to undergo basic tests, they added. Sri Chand Jain was operated upon for a hip ailment for the first time after she took a medi-claim policy. Prior to that, she had been complaining of pain in the left hip and was using a stick for walking.

(T.O.I. dated 6.6.2006)