Gurugram, May 26 : The Gurugram district consumer grievances redressal forum in a recently passed order has said that moderate consumption of alcohol cannot be used as grounds to reject medical insurance claims.
The Forum directed New India Assurance Company Limited to reimburse complainant Giani Ram Saini, 51, Rs 1,28,677 which was incurred by the complainant on his medical treatment along with interest at 9 per cent per annum.
The complainant is also entitled to compensation of Rs 50,000 as well as Rs 22,000 as litigation expenses.
The rejection was on the grounds of Giani Ram Saini had not disclosed at the time of taking the policy that he was suffering from a pre-existing disease “liver abscess being a chronic alcoholic”.
Saini in his complaint said he, his wife and children had held the health insurance policy for the period from February 9, 2018 to February 8, 2019.
In May 2018, he felt abdominal pain and was admitted to the Institute of Liver & Biliary Sciences at Vasant Kunj in Delhi.
Thereafter, conducting the necessary tests, the doctor found a liver infection and the complainant remained admitted for his medical treatment in the hospital from May 8, 2018 to May 14, 2018.The complainant incurred Rs 1,28,677 for his entire treatment.
But the complainant said, his claim for reimbursement was rejected by the insurer company, and he was only discharged after his family paid out-of-pocket.
In its response, New India Assurance Company said Saini had not disclosed at the time of taking the policy that he was suffering from a pre-existing disease “liver abscess being a chronic alcoholic”.
The company said: “As per policy terms and conditions alcohol-related disease is not payable, hence claim does not fall within the purview of the policy terms and conditions, we regret our inability to admit the claim.”
However, the court did not accept the insurer’s argument and sided with the complainant, saying that it could not be proved that the complainant developed of infection or abscess in the liver for which he had been treated as a result of alcohol intake and before he was hospitalized was behind the illness.
According to the decision: “It is a matter of common knowledge that the disease of liver infection resulting in pain abdomen can occur at any time to any person without having known to any previous history of the said ailment.
“It was the burdened duty of the insurance company to conduct thorough medical check-ups on the person of complainant and his family members, to ascertain whether the complainant and his family members had been suffering from any such liver infection or any other disease with any history of account of alcohol or not, at the time of issuing the subject Insurance policy.
“Since, the insurance company did not endeavour or opt to conduct any such medical examination on the persons of the complainant and his family to ascertain as to whether the complainant and his wife were suffering from any such ailment or disease with any history or not, on account of intake of alcohol, at the time of issuing the subject insurance policy,” the decision said.
“So, now the Insurance Company is definitely barred from taking the plea that it had legally, validly and properly repudiated the subject medical reimbursement claim of the complainant as per the policy terms and conditions,” it added.
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