Insurance firm directed to settle Rs 7 lakh medical claim

The forum rejected the ICICI Lombard General Insurance Company Limited’s submission that the petitioner did notdisclose that he has hypertension and diabetes before availingthe policy.

The forum also directed the firm to restore the twopolicies worth Rs 11.2 lakh that were terminated.

The petition was filed by S John Robert, a resident of Tambaram, under Section 12 of the Consumer Protection Act, 1986, to restore the policy contract with full benefits, and to pay Rs 7.26 lakh towards medical expenses. He also sought compensation for sufferings and deficiency in service.

John Robert submitted that he was diagnosed with renal dysfunction in November 2015, when his laboratory blood report came through. Following that, he underwent kidney transplantation on May 24, 2018, at a private hospital in Chennai. When he opted for cashless settlement for the medical bill of Rs 10,46,723, the firm paid only Rs 3.2 lakh to the hospital.

Rejecting his claim, the firm submitted that the petitioner did not disclose that he has hypertension, diabetes prior to the inception of the policy, and added that as per the terms, the policy would be null and void, and that no benefit would be payable in the event of untrue or incorrect statements.

Recording the submissions, forum president M Mony and member R Baskarkumaravel held that the insurance firm was liable to restore the policy contract and to pay a sum of Rs 7.26 lakh.

The firm was also directedto pay Rs 50,000 towardscompensation, with the cost ofRs 10,000.