Ahmedabad: A consumer commission has ordered an insurance company to reimburse Rs 4.25 lakh with interest to a policyholder for her cancer treatment. The ruling stated that her cancer was unrelated to the psoriasis she was suffering from.
According to the case details, a resident of Kalol town underwent surgery in Jan 2024 for cancer. As she had a health cover since 2021 from Care Health Insurance Co Ltd, she decided to opt for cashless treatment at a private hospital.
However, the insurance company not only denied her the cashless service but also rejected her reimbursement claim. They argued that she had not disclosed her psoriasis condition when obtaining the insurance policy, which constituted a breach of policy condition and a violation of the principle of utmost good faith. They later recommended that her husband, a co-holder of the policy, remove her name from the policy. The couple approached the Gandhinagar District Consumer Dispute Redressal Commission through advocate H D Shah, complaining about the unjust rejection of their claim.
They presented an opinion from an oncosurgeon, Dr Kinnar Shah, stating there was no link between psoriasis and cancer. The specialist’s certificate read, “I would like to clarify that psoriasis is a skin condition, not associated with cancer in any way.”
The insurer argued the policyholder had suppressed the condition of psoriasis in her proposal form and hence was not entitled to the claim. After hearing the arguments, the commission stated, “Even if psoriasis was not disclosed in the proposal form, what is important is whether there is any nexus between psoriasis and cancer.”
Heeding expert opinion, it said, “It can’t be said that the complainant hid an important fact. It is not proper on part of the insurer to reject the claim on this ground, and by doing so, it has shown negligence and deficiency in service.”
The panel ordered the insurer to reimburse the claim with 7.5% interest, pay Rs 5,000 towards legal expenses and compensation for causing mental torture to the policyholders.
Ahmedabad: A consumer commission has ordered an insurance company to reimburse Rs 4.25 lakh with interest to a policyholder for her cancer treatment. The ruling stated that her cancer was unrelated to the psoriasis she was suffering from.
According to the case details, a resident of Kalol town underwent surgery in Jan 2024 for cancer. As she had a health cover since 2021 from Care Health Insurance Co Ltd, she decided to opt for cashless treatment at a private hospital.
However, the insurance company not only denied her the cashless service but also rejected her reimbursement claim. They argued that she had not disclosed her psoriasis condition when obtaining the insurance policy, which constituted a breach of policy condition and a violation of the principle of utmost good faith. They later recommended that her husband, a co-holder of the policy, remove her name from the policy. The couple approached the Gandhinagar District Consumer Dispute Redressal Commission through advocate H D Shah, complaining about the unjust rejection of their claim.
They presented an opinion from an oncosurgeon, Dr Kinnar Shah, stating there was no link between psoriasis and cancer. The specialist’s certificate read, “I would like to clarify that psoriasis is a skin condition, not associated with cancer in any way.”
The insurer argued the policyholder had suppressed the condition of psoriasis in her proposal form and hence was not entitled to the claim. After hearing the arguments, the commission stated, “Even if psoriasis was not disclosed in the proposal form, what is important is whether there is any nexus between psoriasis and cancer.”
Heeding expert opinion, it said, “It can’t be said that the complainant hid an important fact. It is not proper on part of the insurer to reject the claim on this ground, and by doing so, it has shown negligence and deficiency in service.”
The panel ordered the insurer to reimburse the claim with 7.5% interest, pay Rs 5,000 towards legal expenses and compensation for causing mental torture to the policyholders.
