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Rajneesh Lakhanpal
Ludhiana, 22 November
The Permanent Lok Adalat (PLA) has directed Religare Health Insurance Company, Gurgaon to pay Rs 8,09,500 for medical expenses incurred by the policyholder, an 86-year-old woman during her visit to Canada.
PLA chairman Balwinder Singh Sandhu and members Anju Garg and Rajwinder Kuar felt that it was unfair on the part of the company to deny the claim on the basis of suppression of pre-existing disease. The PLA observed that there was no suppression of material facts or pre-existing diseases on the part of the complainant.
The verdict came while deciding a complaint filed by Mahinder Kaur, a resident of Moti Nagar in Ludhiana.
The complainant submitted to the PLA that before moving to Canada in 2018, he had purchased a medical insurance policy paying Rs 88,734 for 180 days for his treatment in case of need. While in Canada, he suffered health problems and was transferred to Surrey Memorial Hospital in New Westminster for treatment. He was hospitalized there from March 12 to March 14, 2018. He was entitled to cashless treatment at the hospital and requested the same from the insurance company but his request was rejected due to non-disclosure of pre-existing disease. He thus had to spend 16,738 Canadian dollars out of his own pocket.
After returning to India, the complainant filed a claim with the company on April 5, 2018 along with all relevant documents but his claim was rejected. He did not have any disease for which he was treated before purchasing the insurance policy and thus, the claim was wrongly, illegally and arbitrarily rejected.
The insurance company’s lawyer denied the complainant’s allegations. It was submitted that the claim was rightly denied as he was guilty of suppressing material facts relating to pre-existing diseases of dementia, Alzheimer’s and small vessel ischemic disease.
Counsel also pleaded that as per a medical report done by Surrey Memorial Hospital, the complainant had a history of dementia. Moreover, according to the records obtained from CMC Hospital, he was suffering from ‘forgetting’ disease for the past three years and according to the hospital’s MRI report, he was suffering from structural brain parenchymal abnormalities, small vessel ischemic disease and age-related problems. -related changes but all this information was not disclosed to the company when his medical condition was verified online before he bought the policy.
The PLA observed that since, as per CMCH’s records, the complainant was suffering from forgetful illness and there was no evidence that any of his relatives or family members were with him at the time of purchasing the policy, the complainant may have forgotten to disclose. Her medical report from CMCH, where some minor changes in her brain were found and said to be due to old age.
Therefore, it cannot be said that the complainant had suppressed any material fact while purchasing the policy regarding any previous chronic illness as the previous findings of CMCH were not chronic diseases but the issues were only age-related.
The PLA also observed that the complainant was treated after a seizure during his visit to Canada. According to Surrey Hospital findings, the patient was previously healthy and was not taking any medication at home. Moreover, there was no history of any seizures mentioned in the past. Therefore, denial of his claim was not justified, the PLA held.
The PLA also said that if the compensation awarded is not paid within two months from the date of judgment, the insurance company will also be liable to pay 9 percent interest per annum from the date of rejection of the claim.
The complainant did not conceal the information, the PLA said
The Standing People’s Court did not hold that the complainant, in any way, had suppressed any material information about any previous chronic illness at the time of purchasing the medical insurance policy, as the findings at CMC Hospital were not related to any. Chronic diseases but the problem was only related to age. Therefore, the claim for the medical expenses incurred by him during his stay in Canada cannot be denied.
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