Insurance firms can't reject mediclaims

Insurance firms can't reject mediclaims

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 he or she 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 medical claim policy did not permit interpretation of a particular disease.

“The insurance companies are strictly bound by the disease or ailment specified in the policy as pre-existing disease. No addition 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 related 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.

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