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18-Year Fight Ends: Insurer Loses Medical Claim Appeal
9 Mar
Summary
- National commission dismissed insurer's appeal after 18 years.
- Insurer wrongly rejected overseas medical claim due to non-disclosure.
- Patient's disclosed medical history led to claim being rightfully allowed.
The National Consumer Disputes Redressal Commission (NCDRC) recently dismissed an appeal by Oriental Insurance Company Limited, concluding an 18-year legal dispute. The case involved a 75-year-old Delhi resident who suffered a stroke during a 2008 visit to the United States. The insurer had initially rejected his overseas medical claim, citing alleged non-disclosure of pre-existing conditions.
In June 2008, the individual purchased an overseas travel policy for his trip to New Jersey. While abroad on August 2, 2008, he experienced an ischemic attack and was hospitalized. The discharge summary noted a medical history including bypass surgery in 2003, coronary artery disease, hypertension, and diabetes.
Oriental Insurance repudiated the claim on November 19, 2008, asserting the stroke was a complication of undisclosed medical history. However, the proposal form from June 5, 2008, clearly indicated a history of ischemic heart disease, bypass surgery in 2003, and hypertension. The state commission had previously ruled in favor of the insured, finding no material suppression of facts.
The NCDRC upheld the state commission's decision, stating the insurer's rejection was based on an incorrect assessment of the facts. The commission emphasized that clear disclosures in the proposal form meant the insurer could not later deny liability on grounds of non-disclosure.
