Delhi Ombudsman Centre Case No. GI / 319 / UII / 04 Shri. Darshan Kumar Vs.

United India Insurance Company Limited Award Dated 15.12.2004

The complainant was hospitalized for treatment of Disk Prolapse. The claim was repudiated by the Insurance Company on the ground that the patient had a history of low back ache for the last 20 to 25 years and, therefore, the ailment was pre - existing. The Insurance Company based their decision on a loose remark in the discharge summery, which said that the patient was admitted with complaint of low back ache since 20 yeaRs. Honble Ombudsman held that this is a preposterous remark. A person will not wait for 20 years to get admitted to a hospital for treating a low back ache. The Insurance Company is playing up this trifle with a view to evading liability. The patient (insured person) is driver and a low back ache must be part and parcel of his existence. There is absolutely no evidence Prolapse for the last 20 yeaRs. There is no correlation between Disc Prolapse and so called law back ache. The company was asked to pay the claim for treatment of Disc Prolapse.

Chennai Ombudsman Centre Case No.11.02.1208/2006-2007 Shri. V.R. Kumar Vs The New India Assurance Co. Ltd., Award Dated : 30.11.2006 The complainant Shri. V.R Kumar was covered under Mediclaim policy with M/s New India Assurance Co. Ltd. He was hospitalized for the complaint of Proteinuria and diagnosed to have systemic hypertension, Non-nephrotic range Proteinuria. On submission of claim papers, the Insurer repudiated the claim on the ground of preexisting. Since the present treatment was for Proteinuria and the same was present in the year 2001, the Insurer had repudiated the claim. His main contention was that the treatment was not for the pre-existing disease i.e. hypertension. The Insurer contended that the complainant was a known case of hypertension for 11 years and the same was specifically excluded from the policy coverage. As per the discharge summary he was a known case of hypertension and non-nephrotic range Proteinuria, hence repudiated the claim on the ground pre-existing disease. This Forum observed that the Insurer has gone by the Pre-authorization request form to conclude that the Proteinuria is a pre-existing ailment. But the certification given by the attending doctor and the discharge summary does not contain any significant presence of Proteinuria before 2002. It was also found by this Forum that the insurer have not done any further investigation to establish the presence of Proteinuria before 2002 and the biopsy report was not submitted which only could prove that the hypertension was the cause of Proteinuria. Since, the Insurer had not conclusively established that Proteinuria was pre-existing or that hypertension was the cause of Proteinuria, the claim was allowed.

Delhi Ombudsman Centre Case No. : GI/96/RSA/06 Smt. Yash Verma Vs Royal Sundaram Alliance Insurance Company Award Dated : 29.06.2007 The complaint was heard on 18.06.2007. Smt. Yash Verma was present and the Insurance Company was represented by Shri Ajay. Smt. Yash Verma had lodged a complaint with this Forum on 19.07.2006 that she had taken a mediclaim policy from Royal Sundaram Alliance Insurance Co. Ltd. effective from 25.03.2004. She had met with an accident on 10.05.2005 and received spinal

injuries. Immediately she rushed to nearest clinic where she had been treated by Dr. Attique. After few days doctor advised her to go to specialist and she consulted Dr. Harish Bhargava working in Apollo Hospital. Royal Sundaram Alliance Insurance Co. Ltd. vide their letter dated 20.02.2006 rejected the claim on the grounds that the disease was pre-existing. She further submitted the letter of Dr. Bhargava dated Nil wherein he had mentioned that the disease is not pre-existing. She also confirmed that she had not undergone any treatment for the same, as she had only got injuries on 10.05.2005. She has requested the Forum that her genuine claim be paid. Royal Sundaram Alliance Insurance Co. Ltd. vide their letter dated 12.09.2006 informed the Forum that Smt. Yash Verma had lodged a complaint under their Health Shield Insurance policy which was valid form 25.03.2005 for expenses incurred by her for treatment of L4/ 5 Disc prolapse with right side radiculopathy for the period commencing from 05.09.2005 to 10.09.2005 for a total claim amount of Rs.120157.75/-. The Insurance Company further informed that the claim for cashless service was submitted by the insured which was rejected by their TPA Medicare Services on the grounds that the ailment was pre-existing in view of the medical records, which revealed the ailment as a chronic case. Hence she approached the Insurance Company by way of a claim for reimbursement of expenses incurred. The Insurance Company not only referred the case to the penal doctors who observed that as per MRI report which shows osteophytes and thickening of ligament this could not have developed over 1 years and is definitely pre-existing. The discharge summary dated 10.09.2005 states that the ailment as L4/ 5 Disc Prolapse with right side radiculopathy and the findings states that the L5 nerve root on right side edematous and badly compressed with protruding disc bulge. Moreover, the MRI Dorso- Lumbar spine report dated 110.05.2005 suggests broad based disc prostrusion with moderate right para-central disc extrusion at L4-5 level causing compression of right L5 nerve roots and that are changes of facetal hypertrophy with mild ligamentum flavum thickening. The Insurance Company further consulted the specialist for his opinion, who opined that I have gone through Smt. Yash Vermas policy file, where she was operated for her low back pain, which is 6 months duration. By seeing the reports and complaints the low back pain may be pre-existing one. It is therefore clear from the medical records and opinions of doctors that the ailment for which treatment was undergone by the insured was a preexisting ailment which could not have developed during the currency of the policy and hence excluded under the terms and conditions contained in the contract of insurance. In view of the medical records and doctors opinions, they had repudiated the claim of the insured vide their letter dated 20.02.2006 on the grounds that the ailment of the insured takes longer time to develop and would not have developed after the commencement of the policy and further that the present treatment by way of hospitalization was one for treatment of pre-existing disease, outside the policy purview condition D-Exclusion. They further submitted that the present ailment is a prima facie case of pre-existing disease, which is further confirmed by the opinion of the doctors referred above. They have repudiated the claim after due consideration of the medical records of the insured, based on the medical opinion and proper application of mind. The claim was repudiated, as it was not admissible as per the terms and conditions of the policy. At the time of hearing Smt. Yash Verma informed the Forum that she had slipped from the stair case as a result of which she received spinal injuries and she had never complaints with regard to pain in the spinal cord. She further contested that Dr. H. Bhargava who is renowned Orthopedic doctor has confirmed in his certificate that the disease was not pre-existing as she had no complaint of pain prior to 10.05.2005. The representative of the Insurance Company contested that as per the various reports of their specialist with whom they have consulted and MRI report which shows osteophytes and thickening of ligament which could not have developed during the period Smt. Yash Verma has been insured. Further, she has developed right L5 nerve roots and that are changes of facetal hypertrophy with mild ligamentum flavum thickening in May 2005, as such the ailment L4/5 disc prolapse with right side radiculopathy was there before the policy was taken. On the basis of the medical records and doctors opinion they have rightly repudiated the claim as pre-existing disease since as per exclusion clause D of the policy Pre-existing condition Such

disease /injury which have been in existence at the time of proposing this insurance. Pre-existing condition also means any sickness or its symptoms, which existed prior to the effective date of this Insurance, whether or not the Insured person had knowledge that the symptoms were relating to the sickness. Complications arising from preexisting disease will be considered part of that pre-existing condition. As such as per this condition the disease has been there before the policy was taken in the year 2004. On examination of the papers submitted and after hearing both the parties the Insurance company has consulted two Orthopedic Surgeons and they have mentioned that the disease may be pre-existing one. Dr. H. Bhargava who has examined Smt. Yash Verma at Apollo Hospital when she was admitted on 05.09.2005 in his report dated Nil has mentioned that HNP Herniates disc which can be associated with or without DDD. Patient symptoms took place only after the fall hence she had HNP on top of the DDD. So I think her claim is genuine and was none of pre-existing disease. Dr. Bhargava also mentioned that DDD (Degenerative Disc Disease) which is associated with big flarum thickening and facetal hypertrophy and will be found in 7080% of females above 50 years in MRI scans. Since Dr. Bhargava has mentioned that HNP was a result of fall and DDD could be taken as a pre-existing disease, I therefore pass an Order that Smt. Yash Verma be paid 50% of the admissible claim when she was admitted in Apollo Hospital on 05.09.2005.

Chennai Ombudsman Centre Award No. 11.08.1064 / 2006 - 2007 Shri. K. S. Srinivasan Vs The Royal Sundaram Alliance Ins. Co. Ltd. Award Dated 20.06.2006 The complainant stated that he and his wife were covered under Health Shield Policy with The Royal Sundaram Alliance Ins. Co. Ltd. for the period from 22.10.2005 to 21.10.2006. In December 2005 she underwent Mouth Flap Surgery. His claim was rejected on the ground that it was a pre-existing disease and the hospitalisation was done not more than 24 hours. The insurer repudiated his claim on the ground that the ailment was pre-existing. Insurer contended that the policy was 2 months old but the treatment taken was for chronic periodonitis and the word chronic indicates that the patient was suffering from this ailment for quite sometime. When the Ombudsman enquired what was the definition for chronic in their terms, for which the insurer replied it is six months. The Ombudsman pointed out the chronic means it may be 3 months and not 6 months as stated by the Insurer. Hyderabad Ombudsman Centre Case No.G-11-008-0158 Smt. S.Vijaya Vs Royal Sundaram Alliance Insurance Co. Ltd. Award Dated : 8.11.2007 Brief facts : Smt. Vijaya was insured under a Health Shield insurance policy of Royal Sundaram Alliance Insurance Co. Ltd. The policy was first obtained in 09/2005 and renewed from 29.9.2006 to 28.9.2007 and the sum insured was Rs.100,000. She was admitted into Mallya Hospital, Bangalore on 8.4.2007 with chief complaints of back pain. Laminectomy & Disectomy were done and she was discharged on 14.4.2007. After discharge from the hospital, she lodged a claim for Rs.28,861/-, which was rejected in 05/2007 under pre-existing clause. Complainants contentions: She experienced pain for the first time in Nov/ Dec.2006 and as the pain was not substantial, no significant medical treatment was availed and she even undertook a pilgrimage to North India in Feb./Mar.2007. During the tour she had a fall resulting in aggravation of pain. After her return, she consulted a doctor and

underwent the surgery. Cashless facility was denied and her bill for reimbursement was also denied much against policy conditions. Insurers contentions: The ailment diagnosed was degenerative changes with secondary spinal canal stenosis. The MRI revealed degenerative changes with secondary spinal canal stenosis and hence cashless facility was denied by their TPA. Such an ailment cannot develop in a period of less than two years and hence it must be a pre-existing one. Hence, they rejected the claim. Decision : The complainant stated that she never had any symptoms of the disease before Nov/ Dec 2006, whereas the policy was taken in Sep.2005. The pain aggravated after a fall during a pilgrimage and did not subside with physiotherapy. The insurer stated that the disease could not develop in a span of about one year and seven months. The insurer could not submit any evidence to prove that the insured was suffering from the disease prior to the commencement of the policy. Since no proof was submitted, the complaint was allowed and the insurer was directed to settle the claim.