P.M.Bhat, member, Mysore Grahakara Parishat writes
It has become common for insurance companies to deny health insurance benefits to customers by claiming that the health problem existed before the policy was made and so is not covered under the policy. The insurance companies were earlier denying insurance benefits saying that the customer knew of his health problem but did not disclose it at the time the policy was made. But exclusionary clauses included in newer policies deny policy coverage in case of preexisting health conditions even though the customer might not be aware of them. Such fraudulent clauses give insurance companies sweeping powers to reject almost any health claim. No wonder, such clauses are being challenged more and more, especially before consumer courts, by unhappy policy holders.
In a recent decision (II (2008) CPJ 146 (NC)) which is a godsend to thousands of health insurance policy holders across the country, the National Consumer Commission has come down heavily on this deceitful practice. Relying on an earlier decision, it has said: "The policy which states that it is immaterial whether the insured had knowledge of the disease or not, and even existence of symptoms of the disease prior to effective date of insurance enables the Insurance Company to disown the liability. If this interpretation is upheld, the Insurance Company is not liable to pay any claim whatsoever, because, every person suffers from symptoms of any disease without the knowledge of the same. This policy is not a policy at all, as it is just a contract entered only for purpose of accepting the premium without the bona fide intention of giving any benefit to the insured under the garb of preexisting disease. Most of the people are totally unaware of the symptoms of the disease that they suffer from and hence they can not be made liable to suffer because the Insurance Company relies on the (exclusionary clause) in a mala fide manner to repudiate all claims. No claim is payable under the mediclaim policy as every human being is born to die and diseases are perhaps preexisting in the system totally unknown to him of which he is genuinely unaware."
The Commission observed caustically that if one can foresee disease from some earlier symptom, then every person would do medical studies and not take any insurance policy at all. The Commission also noted that before insuring, the customer is thoroughly checked by the doctors nominated by the insurance company and if at that time he was found hale and hearty, it would be difficult to conclude that he had suppressed a preexisting disease.
So, if an insurance company refuses to meet its obligations under the pretext of preexisting condition, the affected party should file a complaint before a consumer court for relief.