The Consumer Redressal Commission has fined an insurance company Rs 1,57,000 for rejecting a claim because they considered menstruation as a disease. The amount consists of the sum assured, compensation, and legal costs. A person named Subramaniam has maintained a health insurance policy in his wife’s name since 2020. His wife was admitted to a private hospital for treatment. Initially, the insurance company had said that they would approve a certain amount based on the hospital’s report. However, the claim was denied after a review of documents because his wife had consulted a doctor in 2018 for extensive menstrual bleeding. The reasons given were that the insured had consulted a doctor for a certain condition earlier but had failed to disclose it when purchasing the policy.
The commission did not buy the argument, saying that the 2018 incident had nothing to do with the 2023 ailment. It also said that excessive menstrual bleeding is not a disease that requires prior disclosure.
What To Know
There could be situations of claim disputes in cases where some of the natural biological processes are categorized as pre-existing conditions or policy exclusions by the insurers. “The insured could face challenges in such conditions due to varying interpretations of the policy terms. To avoid this, policyholders are highly recommended to read the policy documents well. Also, if the claim is denied in such cases, it must be escalated through the grievance redressal procedure,” says Rakesh Goyal, director, Probus.
Consumer Protection Act 2019, Insurance Regulatory Development Authority of India (Irdai) Health Insurance Guidelines 2020, Pre-existing Disease Guidelines, and Insurance Ombudsman are some of the Indian regulations that could help policyholders in dealing with such unfair situations.
