Page 43 - Insurance Times August 2018

break in insurance due to fault of Bank . He had regularly the period from 31.07.2016 to 30.07.2017 from Oriental
taken the policy from the company for the last five years. Insurance Co. Ltd. for himself, his mother and father. The
mother of the complainant was admitted twice in Vinayak
The premium of the policy of Rs.3399/- was debited from Nursing Home, Jaipur for the period from 10.12.2016 to
his account on 23.08.2016 instead of 26/07/2016 hence the 14.12.2016 and from 31.05.2017 to 02.06.2016 for gastro-
policy period should be effective from 23.08.2016 instead enteritis, dehydration, diabetes and Crohns disease. Two
of 05.09.2016; which is less than one month and very much claims were lodged by the complainant with the company
within grace period. The company stated that the policy, for re-imbursement but the same were rejected by the
on which the claim was reported was renewed after a gap company on the ground of being genetic disease.
of 41 days and the previous policy was also renewed after
a gap of 16 days, hence the current insurance policy was However earlier two or three claims for gastroenterology
treated as a fresh policy. As per terms and conditions of the had been paid by the company. The claimant submitted a
policy there is a waiting period of 2 years for the treatment certificate of Dr. Sanjeev Bhargava, treating doctor, stat-
of cholelithiasis (stone) disease and if continuity of the policy ing that Crohns disease is not a genetic disease and sought
was not maintained then subsequent cover was to be relief from this forum for re-imbursement of the claim of
treated as fresh policy, hence the claim of the complainant his mother.
was rejected by the company under clause 4.2 of the policy,
which states that the expenses on treatment of calculus The company rejected the claim stating that Crohns disease
disease for the period of two years is not payable if con- was genetic, hence the claim was considered as Non-pay-
tracted and/or manifested during the currency of the policy. able as per General Exclusion No.4.15 of the policy, which
The insured did not appear for personal hearing. From the states that ”the company shall not be liable to make any
records, it was noticed that the premium as claimed by the payment under the policy in respect of any expense what-
complainant was debited within one month, confirming the soever incurred by any insured person in connection with
break in insurance is within 30 days. or in respect of –genetic disorders and stem cell implanta-
tion/surgery”.
Hence the Insurer should settle the claim on merit as agreed
by them after condoning the delay, which is less than 30 The complainant did not appear and requested for decision
days. Once this is considered, the treatment of cholelithi- on the basis of records. From the available records, it is
asis would not fall within two years. Hence, an award was observed that origin of Crohn disease need not necessarily
passed with the direction to the insurance company to pro- be genetic as it could be also due to deficiency in immune
vide all the continuity benefits of renewal under the policy system or environmental factors.
to the complainant after condoning the delay.
The insurer also agreed but insisted that main reason is
Mr. Abhishek Bhargava always genetic. It is thus clear that besides genetic, there
may be various other reasons also which may cause Crohns
V/S disease. Hence, the decision of insurance company in re-
jecting the claim is not totally justified. An award was
Oriental Insurance Company Limited. passed with the direction to the insurance company to pay
the admissible claim amount to the complainant. T
The complainant had taken Happy Family Floater Policy for

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The Insurance Times, August 2018 43