HC ruling on insurance companies rejecting medical claims

HC ruling on insurance companies rejecting medical claims

In a significant ruling the Madras High Court bench has said insurance companies cannot reject medical claims reasoning that the disease for which reimbursement had been sought was caused by the claimant's health problems that existed before they took insurance cover.

Allowing an appeal filed by one Manivasagam, Justices R Sudhakar and V M Velumani said there could be several reasons for a pre-existing disease or ailment. The doctors alone could identify them and provide the treatment, they said and ruled that the terms of the mediclaim policy did not permit interpretation of a particular disease.

"The insurance companies are strictly bound by the diseaseor ailment specified in the policy as pre-existing disease. Noaddition or deletion by way of interpretation can be done. The authority cannot read something more into the terms and conditions of the policy and come to the inference that one disease is relatable to other disease and, therefore mediclaim is rejected," the Judges said.

Manivasagam said only hypertension and diabetes were mentioned as pre-existing diseases in his medical claim policy. The policy was renewed periodically, until he spent Rs 1.41 lakh in August 2007 for a coronary angiogram test followed by a bypass surgery.
The insurance company rejected his claim. The single judge also dismissed his petition, asking him to approach the Consumer Disputes Forum in view of disputed questions of fact involved in the case.

The petitioner contended that there was no disputed question of fact in the case.
The Judges concurred and said the dispute arose only due to misconception and misinterpretation of rules by the insurance company and directed it to honour the claim.

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