Can’t deny claim over healed injury, commission tells firm

Ramkrishan Upadhyay

Tribune News Service

Chandigarh, January 17

The District Consumer Disputes Redressal Commission, Chandigarh, stated that a fracture or an injury once healed ceases to be a disease or sickness and an insurance firm cannot deny the claim to a consumer on the basis that he/she concealed such a past injury.

The commission has directed an insurance firm to release the cost of the treatment — Rs70, 000 — of fracture to a consumer who was denied the claim on the plea that the consumer concealed the fact that she had suffered a similar fracture in the past.

The commission also directed the firm to pay Rs15,000 as the compensation for causing mental agony and harassment and to pay Rs10,000 as the costs of litigation to the complainant. Manoj Kumar Sarin, a city resident, approached the commission after the insurance firm denied the claim to her wife.

He said he took Max Bupa Health Insurance Policy for two persons — for himself and his wife — on the payment of Rs41,435 in 2019 and the sum insured was Rs5 lakh each. While the policy was continuing, his wife slipped while cleaning the house on October 20, 2019.

She was taken to the General Hospital, Sector 16, Chandigarh, and her X-ray revealed a fracture in left forearm. The policy was cashless and the complainant decided to undergo the treatment from a specialist. He had then admitted his wife to Healing Hospital, Sector 34. However, the insurance firm denied the claim of Rs70,000 spent on the treatment.

The claim was again submitted with documents, but was rejected again by the company “due to the non-disclosure of facts — operated case of fracture shaft of radius with plating not disclosed”. Manoj Kumar alleged that the act of the insurance company was tantamount to a deficiency in service and unfair trade practice.

The insurance firm denied the allegations and justified the rejection of the claim by saying that the complainant’s wife had a history of the disease.

After hearing the arguments, the commission noted that the wife of the complainant had a fresh injury and suffered a new fracture which is unrelated to any previous injury and she was functioning absolutely normal for the past five years. A fracture once healed not a pre-existing disease. “Hence, there is no question of concealment of previous disease when it ceased to be a disease after the treatment 4-5 years ago. Hence, the rejection of the claim by the company clearly amounts to deficiency in service and unfair trade practice,” stated the commission.