Case Study: Kumar had
obtained a Travel Super Age Lite policy from Bajaj Allianz General Insurance before travelling to America. He was charged a premium of Rs 44,090 for a policy valid from May 4 to May 26 2012.
In New York, on May 14, he developed chest pain and palpitation and was rushed to NYU Hospitals Centre. He was hospitalized overnight and discharged on May 15. The total hospital bill came to US$12,532.13. Kumar lodged a claim in which he disclosed that in about 15 years ago, he had undergone a bypass surgery in 1997 for a cardiac problem. Citing heart problem to be a pre-existing disease, the insurance company repudiated the claim.
Kumar filed a complaint before the Central Mumbai District Forum. He pointed out that after the bypass surgery, he had been leading an active and normal life. He used to periodically get himself checked up. The stress test reports prior to travelling abroad and even on returning were normal. He pointed out that a person with a heart problem would not be discharged and fit in 24 hours of hospitalization. Even the treating doctor had certified that the sudden chest pain and palpitation were not due to the earlier cardiac problem.
The insurance company was served with a notice by the forum, but did not bother to appear on two consecutive dates, so the forum decided to proceed ex parte. The insurance company then tried to contest the matter, to which permission was denied. Its appeal to the state commission against this order was also rejected. The company was allowed to argue the matter before the district forum.
The forum observed that the insurance company had failed to contest the case by producing the proposal form to substantiate its contention about pre-existing disease. Relying on a judgment of the national commission in the case of New India Assurance Co v/s Vasant Rao, the forum concluded that heart problem could not be considered to be pre-existing after a successful bypass surgery as Kumar had been leading a normal life since the past 15 years. Besides, the claim form signed by the hospital's doctor, specifically mentioned that the illness was not due to any pre-existing condition. The forum held that the repudiation was unwarranted and constituted a deficiency in service.
Accordingly, by its September 1 judgment, delivered by B S Wasekar for the bench along with H K Bhaise, the forum directed the insurance company to pay USD 12,482.13 to NYU Hospital Centre and report the compliance. It also awarded
Kumar Rs 10,000 as compensation and Rs 5,000 towards costs of litigation.
Impact: Since foreign exchange rates keep on fluctuating and there could be a wide variation in the rate when the insured is hospitalized and the complaint is decided, it is preferable to make a claim in US dollars. Also, since this money is payable to the hospital and not to the insured, it is more convenient if the insurance company is directed to make payment directly to the hospital.
(The author is a consumer activist and has won the government of India's national youth award for consumer protection. His e-mail is jehangir.gai.articles@hotmail.com)
Since foreign exchange rates keep on fluctuating and there could be a wide variation in the rate when the insured is hospitalized and the complaint is decided, it is preferable to make a claim in US dollars
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