State Consumer body directs insurer to pay higher health insurance claim

Complainant had undergone a knee replacement surgery and his claim was settled only partially

September 07, 2022 11:37 pm | Updated 11:37 pm IST - CHENNAI

The Tamil Nadu State Consumer Disputes Redressal Commission, Chennai has directed insurer The New India Assurance Co. Ltd., to pay a higher claim amount to a consumer.

In his complaint, J.D. Ramanathan said he was covered under a group medi-claim policy from 2005-2006. It was periodically renewed and the sum insured under the policy increased to ₹4 lakh for the period 2009-2010.

As per the complaint, Mr. Ramanathan underwent a knee replacement surgery for his right knee and the total hospital expenses incurred was ₹2,34,000. The claim was settled partially, with the insurer sanctioning a sum of ₹1,05,000 as against the entitlement of ₹2,15,000, which is 50% of the sum insured of ₹4 lakh plus cumulative bonus.

In its response, the insurance company stated that the knee pain was a preexisting disease. And as per clauses of the policy, the indemnity for knee replacement is 50% of the sum insured for one knee.

While another clause states that in case of a pre-existing disease, the claims would be admitted taking into account the lease of sum insured for the preceding four policy years or the actual sum insured under the current policy period whichever is less, it added.

Based on this, the insurance company said it allowed ₹1,05,000 which is 50% of the sum insured of ₹2 lakh plus cumulative bonus at that time.

The District Consumer Disputes Redressal Forum, Chennai (South) had ruled in favour of the insurance company, against which Mr. Ramanathan had appealed.

The Tamil Nadu State Consumer Disputes Redressal Commission noted that knee pain is a normal wear and tear in old age and Mr. Ramanathan had said that though he was suffering from knee pain previously, he had not gone to any hospital for treatment.

Therefore, knee pain cannot be taken as a pre-existing disease. Normally, the knee pain may lead to surgery or may not. Hence, considering the condition in the policy is not proper, it ruled.

It said the complainant is eligible for a claim of ₹2,15,000 and ordered payment of a higher balance amount of ₹1,15,000 and ₹25,000 towards cost for litigation.

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