State consumer body orders insurer to pay higher health insurance claim

The complainant had undergone knee replacement surgery and his claim was only partially settled

The complainant had undergone knee replacement surgery and his claim was only partially settled

The State of Tamil Nadu, Chennai Consumer Disputes Redress Commission ordered the insurer The New India Assurance Co. Ltd. to pay a higher claim amount to a consumer.

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

According to the complaint, Mr. Ramanathan underwent right knee replacement surgery and the total hospital costs incurred amounted to ₹2.34,000. The claim was partially settled, with the insurer sanctioning a sum of ₹1.05,000 against the entitlement of ₹2.15,000, or 50% of the sum insured of ₹4 lakh plus cumulative bonus.

In its response, the insurance company said the knee pain was a pre-existing condition. And according to the terms of the policy, the indemnity for knee replacement is 50% of the sum insured for one knee.

While another clause stipulates that in the event of pre-existing illness, claims would be admitted taking into account the lease of the sum insured for the previous four years of insurance or the actual sum insured under the period of insurance ongoing, whichever is lower, he added.

Based on this, the insurance company said they 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 favor of the insurance company, against which Mr Ramanathan had appealed.

The Tamil Nadu State Consumer Disputes Redress Commission noted that knee pain is a normal wear and tear in the elderly and Mr Ramanathan said that although he previously suffered from knee pain, he does not had gone to any hospital for treatment.

Therefore, knee pain cannot be considered a pre-existing condition. Normally, knee pain may or may not require surgery. Therefore, considering that the condition in the policy is not appropriate, it ruled.

He said the plaintiff was eligible for a claim of ₹215,000 and ordered payment of a higher balance of ₹115,000 and ₹25,000 for court costs.

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