Indian Express
2, March 2010
By Utkarsh Anand
New Delhi, India

THE Delhi Consumer Commission has reproached ICICI Prudential Life Insurance Company for refusing to reimburse medical expenses of a patient who underwent treatment at a city hospital following a heart attack.

The insurance company had refused to reimburse Anil Kumar Jain’s medical expenses on technical grounds. But the consumer commission, in a recent judgment, dismissed the company’s appeal against a consumer forum order and asked it to pay around Rs 2 lakh to Jain.

Jain was admitted in St Stephen’s Hospital in November 2007 after suffering a heart attack. He was discharged a week later and approached ICICI Prudential Life Insurance Company to get the medical expenses reimbursed under the policy cover.

The company, though, said the kind of heart complications Jain suffered was not covered under Jain’s policy.

According to ICICI Prudential, Jain suffered medical complications due to a reduced supply of blood to the heart, and the insurance cover was exclusively for heart attacks in which blood supply to the heart stops completely.

But in an order that could have ramifications for all policy holders, Delhi Consumer Commission president Barkat Ali Zaidi said creating a device to escape paying medical insurance money to consumers amounts to “defrauding and cheating”. Zaidi said insurance companies cannot add conditions that are very difficult to be fulfilled even by those who suffer serious ailments.

“It is not open to insurance companies to provide such particulars and details of diseases which quite often do not appear, and which may provide a ground to the companies to avoid payment of compensation,” the Commission ruled. Taking up Jain’s case, Justice Zaidi said it was unreasonable to assume all sorts of heart diseases would have the same pattern of medical complications. “Symptoms appearing in all kinds of heart ailments cannot always be the same,” he held.

“Merely because all symptoms are not the same, the insurance companies cannot avoid the compensation.”

The Commission also slammed ICICI Prudential for arguing that a consumer must be aware about the terms and conditions in his or her policy document. “Judicial ethics become obliterated where there is fraud and deception,” Justice Zaidi said. “Insertion of details which may not get noticed, and (is) put in place to act as an embargo when demand for compensation is made, is not ethical.”

The Commission said it was manifest in Jain’s medical records that he suffered a serious heart ailment, so the company could not be allowed to escape accountability.