Hospitalized for an illness? However the insurer discovers that you did not disclose another disease which was pre existing. What happens now? Will the insurer honour the present claim? Find out from the Ombudsman's ruling in the following case:

Dispute between                    Putcha Venkata Narasimhan vs. Religare Health

Award/Complaint no            IO/HYD/A/HI/0150/2019-20

Cause of dispute                    Pre existing disease

Amount of claim                    USD 9278.29

Relief sought                          USD 9278.29

Decision in favour of             Insurer

Date of Award/Order            03/02/2020

Location                                  Hyderabad

Brief facts

The complainant had purchased a worldwide travel insurance policy. While in the USA ,he was diagnosed with Hiatus Hernia and hospitalized. However, his claim was rejected by the insurer. The Insurer stated that the Insured Person did not disclose Hypertension in the proposal form.

The complainant produced certificate from his doctor stating that he did not have Hypertension.

The insurer submitted that from the perusal of the discharge summary it was clear that the complainant had history of Hypertension. Earlier prescriptions dated 2015 and 2016 also established the same. Hence the claim was rejected due to non disclosure of pre existing disease. Also he was hospitalized for less than 24 hours. And any life threatening treatment caused by pre existing disease was covered under inpatient treatment only.

Ombudsman's ruling

Prescriptions dated 26/10/2016 and 08/12/15 advise Tablet Ecosprin Av75 which is used for treatment of Hypertension, heart attack etc. .In another prescription dated 08/04/2018, he was advised to take Tablet Cardace Protect 2.5 which again is for treatment of Hypertension. In the discharge summary dated 30/07/2018, the patient was asked to take another drug for Hypertension. This shows that the patient already had Hypertension. A certificate from the doctor that the patient did not have Hypertension cannot be considered credible under the circumstances. Also the hospitalization was not for a life threatening ailment. Hence the decision of the insurer is justified.

Remarks:

Discharge summary and other prescriptions were given precedence over the certificate provided by the doctor. Also, the Doctor’s certificate was submitted after the repudiation of the claim which did not go in the favour of the complainant.