Cashless Claim rejected stating non-disclosure of pre-existing disease Cashless Claim rejected stating non-disclosure of pre-existing disease

I was insured with group health insurance and I recently quit my job and I requested to port my group insurance to individual. At first, the insurance provider denied porting and after complaining to IRDAI they agreed to port my group policy to individual upto to the sum of the group policy. The porting application was sent through the company insurance agent and I got my individual policy. I had made a claim (In group insurance) related to my pre-existing condition last year and the insurance provider approved and reimburesed the claim amount. Now, after porting to individual insurance (same insurance provider) I had to undergo another surgery for the pre-exiting condition and went for a cashless claim, but the insurance provider rejected the claim stating non-disclosure of pre-existing condition. 1. In the new policy there is a reference to group policy number, porting and the portability waiver period. 2. Since, I had already made a claim the insurance provider should have all the documents. 3. Honestly, I had no intention of not disclosing the pre-existing condition, infact I had informed to the insurance agent before purchase of the policy. Can the insurance provider reject a claim stating non-disclosure ? Since, it is the same insurance provider for both group and individual and there is a protability waiver period, so automatically all the existing conditions have to be covered right ?. Thanks in advance.

Anik

Responded 3 months ago

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A.Respected sir/ma'am,
Kindly look into the case of
Religare Health Ins. Co. Ltd. vs Harwant Singh And Another on 8 February, 2021.

You can file an application in the STATE CONSUMER DISPUTES REDRESSAL COMMISSION
Section 19 of the General Insurance Business (Nationalization) Act, 1972 states that it shall be the duty of every Insurance Company to carry on general insurance business so as to develop it to the best advantage of the community. The denial of medical expenses reimbursement is utterly arbitrary on the ground that diseases, in question, were pre-existing disease. It is mere an excuse to escape liability and is not bona fide intention of the insurance company. Fairness and non-arbitrariness are considered as two immutable pillars supporting the equity principle, an unshakable threshold of State and public behavior. Any policy in the realm of insurance company should be informed, fair and non-arbitrary. When the insurance policy has exclusions/conditions to repudiate the claim or limit the liability, the same must be specifically brought to the notice of the insured and are required to be got signed to show that such exclusions and conditions have been brought to his/her notice.

22. The need for interpreting a contract always arises in two situations, (i) when a gap is needed to be filled in the contract and (ii) an ambiguity is needed to be resolved in the contract, then to find out correct intention of the contract, spirit behind it is required to be considered. Normally, the insurance policy is a contract of adhesion in which other party is left with hardly any bargaining power as compared to the insurer. Insurance contracts are standard form contracts and are drafted by the insurance company and as such, insurance company is at higher footing than the insured. The benefit of such clause, as exclusion clause, would go to the insured unless the same is explained in clear terms by the insurer. In such circumstances, the tribunal would be more oriented towards the interpretation which goes against the party who has inserted/drafted the disputed clause in the agreement/contract. The adjudicating authority is required to look into whether the intention of the party is to exclude or limit liability has been appropriately explained to the other party or not. This Commission while interpreting insurance agreement is to honour the intention of the parties, who have signed the agreement. Even if the agreement had general exclusion/condition for misrepresentation still fraudulent misrepresentation and non-disclosure may not be there. The innocent and negligent misrepresentations are to be ignored.
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