I had taken a medical insurance policy two years ago. Last year I was admitted to a hospital for hypertension and swelling all over my body. Since I am suffering from a chronic kidney problem, the doctor did a kidney biopsy and discharged me the next day. During the hospital stay, I was treated with anti-hypertensive medicines, which proves that I was not admitted only for investigations. My claim was repudiated for the reason that I was “admitted for investigations” and “pre-existing disease”. How can I claim the expenses?
P Kurien, Vile Parle
Insurance policy being a contract, revealing true and correct information is its essence. Thus, ‘nondisclosure of pre-existing condition’ can be a valid reason for repudiating the claim. Therefore, firstly ascertain if you have disclosed your medical condition of ‘chronic kidney problem’ in the proposal form. In case you have not disclosed it, claim for hospitalisation for any conditions secondary to chronic kidney problems can be repudiated. From your version, it looks like you were admitted for conditions secondary to chronic renal problems. This assumption is further strengthened because of ‘renal biopsy’. Also go through the terms and conditions of the policy, especially the exclusion clause. Many times, certain investigations/health conditions are expressly excluded from the policy cover, or may be for some specific period after the inception of the policy (usually two years). If the policy is issued despite disclosure about your medical condition of ‘chronic kidney problem’ in the proposal form, your claim cannot be repudiated unless it is expressly excluded from the policy. The view taken by the Supreme Court in ‘Manmohan Nanda vs United India Assurance Company Limited’ supports your case. Here, the Supreme Court has held that once the policy is issued after assessing the medical condition of the insured, it cannot repudiate the claim for the same, which was disclosed by the insured in the proposal form, though it has led to a particular risk in respect of the claim in question. Thus, you can approach the insurance ombudsman. If your dispute is not resolved satisfactorily by the ombudsman, you can lodge a complaint before the District Consumer Disputes Redressal Commission.
My husband, while taking a bath, slipped and had a fall. He suffered multiple injuries on his face and head. He succumbed due to these injuries. I had lodged an accident benefit claim with the insurance company. But my claim was repudiated by it on the ground that the death was not proved to be due to an accident. How should I proceed against this?
S Malgaonkar, Panvel
‘Accident benefit’ gives you an additional sum equal to the assured sum, if the death of the life assured resulted solely and directly due to bodily injuries sustained from the accident. But the same has to be proved either by a police report or hospital record. This position is confirmed by the National Commission in LIC India vs N Shankar Reddy.
So, for claiming under accident benefit, you will have to submit the police report and all hospital records along with the doctor’s certificate indicating that the death was solely due to the injuries suffered. If despite the production of all these documents your claim is repudiated, you can approach the District Consumer Commission.
I paid a renowned tour company in November 2019 for a 15-day Europe tour, which was to start on March 26, 2020. Unfortunately, due to the lockdown, the tour was cancelled. Now the tour operator is not ready to refund. He is compelling us to join their future tour. But for the future tour, we will have to pay the cancellation charges as well as the difference between the tour cost. Since my wife had a heart problem last year, we cannot go on a long tour. Please advise me on how to get the refund.
Shrikant Joshi, Mumbai
There are many such tourists fighting for the refund of the tours cancelled during Covid period. Mumbai Grahak Panchayat has filed representative complaints on behalf of such consumers before the Central Consumer Protection Authority (CCPA) against a few of these tour companies. CCPA was pleased to order a refund of 75% of the amount immediately and reserved its decision on the remaining 25% amount in a few of these complaints. But this order has been stayed and now the matter is pending before the High Court. Since you have not mentioned the name of the tour company, I can’t ascertain whether your tour was the party to these complaints. Therefore, you can lodge a complaint as an individual consumer before the District Consumer Commission, if you are not able to settle the issue amicably through mediation.
(Dr Archana Sabnis is an expert on consumer laws who is practising at consumer disputes redressal fora at district, state and national levels since 2000. She is on the panel of conciliators of Maha RERA and is associated with the Mumbai Grahak Panchayat.)