Mediclaim Cos cannot fool clients by playing with words: Court

When St Stephen’s Hospital handed A.K. Jain a bill of Rs 1.91 lakh after heart surgery, he remained cool. He expected full reimbursement from his mediclaim policy with ICICI Prudential Life Insurance. To his shock, the company declined to pay, saying “his disease did not correspond to the symptoms laid down in the insurance cover”. It was pointed out “no muscle of heart became dead” and “no elevation of enzymes was noted ”, and “no changes were found in the ECG”.

“The death of a portion of heart muscle as a result of inadequate blood supply as evidenced by an episode of typical chest pain, new ectrocardiaographic changes and by elevation of the cardiac enzymes. Diagnosis must be confirmed by a consultant physician.”

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This is not the description of a heart disease in a medical journal but definition of the now common heart attack in the policy of a prominent life insurance company.

When St Stephen’s Hospital handed A.K. Jain a bill of Rs 1.91 lakh after heart surgery, he remained cool.

He expected full reimbursement from his mediclaim policy with ICICI Prudential Life Insurance.

He had suffered a heart attack on November 11, 2007. A stent was placed in the veins to regularize blood flow.

To his shock, the company declined to pay, saying “his disease did not correspond to the symptoms laid down in the insurance cover”. It was pointed out “no muscle of heart became dead” and “no elevation of enzymes was noted ”, and “no changes were found in the ECG”.

Not ready to take the injustice lying down, Jain moved the consumer court.

Two-and-half years later, on Tuesday, Jain got justice with the Delhi State Consumer Commission asking ICICI to reimburse full amount and a compensation of Rs 8,000. The panel termed ICICI’s definition of ‘heart attack’ as laying down of rare symptoms deliberately to deny reimbursement.

In a message to all companies, the panel headed by Justice Barkat Ali Zaidi said it is not open to a insurance company to insist on symptoms and details which often do not appear to escape payment of compensation. “It amounts to defrauding and cheating the customer”.

Symptoms of all heart ailment cannot always be the same and cannot match 100 percent”, said the panel upholding a district forum order.

Countering ICICI’s argument that Jain had signed the document with their conditions, the panel said such minute details are generally glossed over and citing them to deny payment was “fraud and deception”. “The spirit of the agreement (between the company and policy holder) must be assumed to be such as to provide relief in case of any heart disease.