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Case Review: Insurance
Summary of some of the decisions made by the Mediators on some of the complaints received by FMB.
This summary is for information only and should not be used for other purpose.
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IMB/1879/L - Non-disclosure of Pre-Existing Illness
The insurers declined the assured's claim for hospitalization benefit on the ground of non-disclosure of pre-existing illness ( hypertension ) in the proposal form dated 6.03.2003. The decision was based on the medical form ( drafted by MCO ) dated 23.02.2004 that the assured has been suffering from hypertension for a few years.
It was observed that the medical form does not contain sufficient information on the assured's hypertension in particular the date of diagnosis, the name of the doctor who made the diagnosis, the blood pressure reading and the treatment / medication prescribed. The information on the hypertension as contained in the medical form was not medically ascertained but was merely based on the information allegedly provided by the assured to the doctor who completed the medical form. It is insufficient to rely on the information given by the assured to the doctor as the assured is not a medically trained person and without ascertaining the basis upon which it was obtained it may turn out that the information given is misconceived.
Since there was insufficient evidence that the assured was diagnosed as suffering from hypertension prior to completing the proposal form, the Mediator held the insurers liable to settle the assured's claim.
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