Doctor Errs, Man Wins Insurance Claim 6 Years Later
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13 August 2010
By Rebecca Samervel
A district consumer forum has thrown its weight behind insurance policy holders, saying they should not be made to pay for their doctors’ mistakes.
The Mumbai Suburban District Consumer Disputes Redressal Forum last week ordered an insurance major to pay its client his full claim amount plus Rs 5,000 as costs after it had refused to pay him a single paisa for more than six years. The reason: Malad resident Navneet Zatakia’s doctor had initially certified him as suffering from hypertension for "five years’’ when it should have actually been "five days’’.
Zatakia’s cardiologist rectified the error by issuing another certificate later, but that was not enough for Oriental Insurance Company.
‘Hypertension can’t be a pre–existing ailment’
Mumbai: Six years after undergoing a heart surgery, Navneet Zatakia finally has a reason to smile. The Mumbai Consumer Disputes Redressal Forum has ordered Oriental Insurance to pay him his full claim of Rs 2 lakh with 9% interest from 2006 along with Rs 5,000 as costs.
On November 11, 2004, Zatakia suffered chest pain and consulted a cardiologist in Ghatkopar. He had to be hospitalised for five days, during which he underwent various tests like an angiography (which revealed blockages in the veins leading to the heart). He was subsequently admitted to a heart hospital and underwent a coronary artery bypass.
He spent over Rs 2.4 lakh and submitted his claim to Oriental Insurance and followed it up with all the requisite documents and information. However, in a letter on February 2, 2005, the insurer rejected his claim.
Zatakia alleged that his claim was rejected as, in the admission and discharge card, the cardiologist he first consulted in Ghatkopar inadvertently mentioned that he was suffering from hypertension for five "years’’ instead of five "days’’.
Zatakia then filed a complaint in the consumer forum on April 5, 2007.
The insurance company argued that the theory–of changing the initial entry of five years to five days–was "incomprehensible’’ as Zatakia was on a tablet called Enampril, which showed that he was suffering from ischaemic heart disease. "Since this fact was suppressed in the proposal form, the contract of insurance vitiated and the claim was not payable,’’ said the insurance company.
But the forum, presided by J L Deshpande and comprising members D S Bidnurkar and V G Joshi, pointed out in its order that the reports–submitted by the hospital–did not mention hypertension and recorded that Zatakia was all right till the evening of November 11, 2004; and, under the caption "past history’’, it was mentioned that there was no history of significant illness. The forum also took into account the discharge papers of the heart hospital which made no mention of Zatakia suffering from hypertension since five years."These facts substantiate the certificates issued by the cardiologist,’’ the forum observed.
"Hypertension, assuming that it was there, may precipitate the cardiac problem but that in itself cannot be the disease. There is no material on the record to show that Zatakia had knowledge of this fact when he purchased the mediclaim,’’ said the forum.
The forum also pointed out that, according to the provisions of the Insurance Act: "Suppression of fact must be of a material fact and to the knowledge of the insured...in this case there is absolutely no material on the record to show that, before undergoing heart surgery, Zatakia had knowledge or was suffering from ischaemic heart disease or hypertension.’’ Citing a National Consumer Disputes Redressal Commission order, the forum observed: "Even if he was suffering from hypertension and was taking a tablet, that cannot be a pre–existing ailment.’’