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Insurance company directed to settle claim with interest to smoker

Last Updated: Oct 27, 2011 | 2361 Views

Over the years, insurance policies and the clauses listed under them have received aInsurance Claim Settlement makeover. This is evident in the case observed by consumer forum between Mumbai resident, Hemant Shah and New India Assurance Company.

Shah, a senior citizen, had purchased a mediclaim policy called hospitalization and domiciliary benefit policy in March 1997 covering self and his wife.  In 2009, he underwent endobronchial biopsy, bronchoscopy and chemotherapy. After contacting the third party administrator (TPA) for claim settlement, he received a letter from them stating that the claim had been rejected. TPA is an intermediary appointed by the insurance company to maintain database of the policyholders, issue identity cards to them, and handle all issues and claims after policy issuance which also includes claim settlement. The reason mentioned in the letter stated that the insurance company had introduced a new exclusion clause in the policy in the year 2007. According to this new clause, use of tobacco leading to cancer was a permanent exclusion.

Since Shah was a smoker, he would not receive the expenses incurred on treatment of cancer. The policyholder then, approached the consumer disputes redressal forum in August 2010. The forum observed that the insurance company should have relied only on the conditions of the original policy and by not doing so, was guilty of deficiency in service and unfair trade practice. If there is any change in the terms and conditions of the original policy, then such a policy becomes a new one, the forum stated.

Shah should get Rs 2 lakh plus 9% interest for the claim one policy and Rs 73 ,038 plus 9% interest on another policy. In addition to this, he should also receive Rs 2,000 towards cost of the complaint.
 

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