For insurance, disease pre-existing only if doc duly certifies it

The disease cannot be said to be pre-existing if it was merely opined so by the doctor on basis of talks with the patient, the forum said while asking the National Insurance Co Ltd to pay Rs 75,000 to a policy holder for rejecting his claim for reimbursement of his wife's treatment expenses.

"The disease in order to be pre-existing should be in the knowledge of insured," the New Delhi District Consumer Disputes Redressal Forum said.

"If a doctor on talking with a patient gives a particular name to a condition explained by patient, it is not sufficient as a positive evidence of pre-existing disease for purpose of insurance," the bench presided by C K Chaturvedi added.

The forum's order came on the plea of Delhi resident Padam Sain Dhingra, who had alleged that the National Insurance Co Ltd had arbitrarily rejected his claim of Rs 50,000 incurred by him on treatment of his wife.

Dhingra's wife was admitted to Max Balaji Hospital on complaint of breathlessness on December 23, 2008 and was discharged on January 22, 2009.

The insurance company had contended that she suffered from heart problems since 2005 and as the policy commenced from 2006, it was justified in rejecting the claim.

The bench did not agree with the insurance company's contention, saying "it has no direct positive evidence of any known sickness of insured, except observation of doctors, made in discharge summary."

The bench observed that the doctor in his discharge summary had recorded that the patient suffered from heart disease since 2005 "on the basis of inference or talks".

Pointing out that the company "arbitrarily repudiated the claim", the bench directed it to pay the Rs 50,000 and also pay Rs 25,000 as compensation for harassment and litigation expenses.