The internal circular of an insurance company stating the exclusion of diseases from a medical insurance policy are not binding on the consumers, said the Mumbai district consumer forum while awarding Rs1.5 lakh as compensation to a man for health insurance claims that had been denied to him.
The forum, while directing the insurance company to clear the mediclaim amount, along with interest, said that consumers are not privy to internal circulars.
The forum held that the companies cannot impose new terms and conditions under the garb of in-house circulars for an existing policy.
The complainant, Kaushik Pandya, said that his wife Rupa, suffered from ARMD (Age-Related Macular Degeneration) illness from 1989 because of which she was unable to see with the left eye. In January 2009, the couple had signed up for a health insurance policy.
Pandya said that at the time of treatment to her right eye (which had been on-going since 1989) her eyes were bandaged. She also suffered from hypertension, diabetes and other ailments. The doctor had then advised that she get admitted to the hospital. The complainant alleged that after the treatment, the insurance company rejected the mediclaim for the treatment of his wife, estimated to be worth Rs1.5 lakhs. Following the rejection of the claim, Pandya filed a complaint in October 2010.
The insurance company had contested the claim and contended that it had been conveyed to the complainant that the nature of the treatment fell outside the scope of the health policy. Hence, the mediclaim had been denied.
The company relied on a circular, dated February 2009, that stated that for the treatment of AMRD, drugs like Avastin or Lucentis or Macugen along with other related drugs are given as an interval injection and is counted as an OPD treatment. The treatment is excluded from the scope of the cover, they argued.
The forum heard both sides and observed that as the complainant was not privy to the said circular it cannot be considered to be binding on him. “The Opposite Party (the insurance company) has imposed new terms and conditions under the garb of a circular in the existing policy, the same cannot be done without the consent or to the knowledge of the policy holder,” the forum said.
The forum has asked the insurance company to pay the claim amount of Rs1.5 lakhs with 9% interest. The forum has also asked that Rs20,000 be paid as compensation for mental agony and Rs5,000 be paid towards the hardship caused to Pandya for the legal proceedings.