Why origin of a disease is important when a claim is made?
 

Dispute between                     Bheem A Sankaran vs. Star Health

Award/Complaint no              IO/HYD/A/HI/0163/2019-20

Amount of claim                     22000

Relief Sought                          22000

Decision in favour of              Insurer

Date of Award/Order             11/02/2020

Location                                  Hyderabad

Brief facts

Inception date of the policy was 08/12/2017. On 23/09/2019, the Insured Person was diagnosed with Cellulitis in her right forearm. The insurer rejected her claim as it emanated from Diabetes Mellitus which had a waiting period of 48 months in the policy.

The complainant submitted a certificate from the treating doctor which showed that Cellulitis resulted from accidental injury and not because of Diabetes Mellitus.

Ombudsman's ruling

Diabetes Mellitus weakens the immune system.. In this case, injury was aggravated due to Diabetes Mellitus. Therefore waiting period of 48 months would apply. The decision of the insurer is justified.

Remarks

Diabetes Mellitus was included as a PED in the policy. This implies that Diabetes Mellitus and any illness which can be sourced to Diabetes Mellitus will not be covered till the waiting period is over, in this particular case, for 48 months.

 

 

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