Cough And Fever Can't Be Classified As Pre-existing Diseases, Chandigarh District Commission Holds TATA AIG General Insurance Co. Liable For Repudiating Claim

Brief Facts:

The Complainant acquired a Medical Insurance Policy from TATA AIG General Insurance Company Limited (“Insurance Company”). She disclosed that she was suffering from asthma and paid an additional premium of Rs. 1,129 /- for it. Subsequently, feeling unwell, she was admitted to Max Super Speciality Hospital, Mohali (“Hospital”) for 8 days. Despite the hospital's pre-authorization request to the insurance company, the claim was rejected stating that there were undisclosed cough symptoms. After being discharged, the Complainant had to settle a hospital bill amounting to Rs. 3.00 lakh. Despite subsequent requests for reconsideration of the claim, the insurance company repudiated the same by giving frivolous remarks such as the unavailability of cashless facilities. Feeling aggrieved, the Complainant approached the District Consumer Disputes Redressal Commission-II, U.T. Chandigarh (“District Commission”) and filed a consumer complaint against the insurance company and the hospital.

Upon receiving notice, the insurance company argued that the Complainant was hospitalized due to symptoms such as a productive cough for three months, fever for fifteen days, shortness of breath for five days, nausea, vomiting for a week, and an inability to take orally, ultimately diagnosed with ABPA and DM-II. It argued that the onset of the cough three months before policy inception rendered it a pre-existing condition which made it ineligible for coverage until 48 months of continuous coverage. Furthermore, the insurance company contended that the request for reconsideration of cashless authorization was duly evaluated but ultimately rejected. It stated that cashless services couldn't be extended at that juncture and advised the Complainant to proceed with reimbursement.

The hospital didn't appear before the District Commission for proceedings.

Observations by the District Commission:

The District Commission noted that the insurance company rejected the claim citing pre-existing conditions, namely cough, fever, and diabetes, which were purportedly present before the inception of the policy. However, the District Commission rejected this argument and noted that these symptoms are common ailments of modern life, manageable with standard medication, and cannot be classified as pre-existing diseases. Moreover, the Complainant disclosed her asthmatic condition to the Insurance Company before the insurance of the policy.

The District Commission referred to the decision in Delhi State Commission Life Insurance Corporation of India Vs. Sudha Jain [II (2007) CPJ 452] noted that everyday maladies like hypertension, diabetes, occasional pain, cold, headache, arthritis, and similar conditions are part of normal life's wear and tear and can't be grounds for claim rejection unless the insured is hospitalized or operated upon for treatment shortly before obtaining the policy.

Consequently, the District Commission held the rejection of the Complainant's genuine claim by the insurance company as illegal and unjustified. The District Commission directed the insurance company to reimburse the claim amount of Rs. 3,00,000/- to the Complainant along with interest at 9% per annum from the date of claim repudiation until realization. However, the complaint against the hospital was dismissed.

Case Title: Anjna Sharma vs TATA AIG General Insurance Company Limited and Anr

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