Pre-existing Disease

 I have taken mediclaim policy in the name of my Mother Mrs. Nanda Arun Dharmadhikari from the Oriental Insurance Co. Ltd., in the year 2001-2002.  Since then, without breaking and lapsing the policy, I have continuously renewing the said policy till this year i.e. 2009-2010. The sum assured of my mother  from 2001-2002 to 2005-2006 was Rs. 15,000/- and from 2006-2007 to 2009-2010 is has compulsorily being increased by the Insurance Company to Rs. 50,000/-.  On 22/03/2010, I have admitted my mother to ‘Deenanath Hospital’, Pune as she suffers from pain Rt.Hip, Rt.Lower Limb, Difficulty in Walking.  After investigation, doctor’s final diagnosis was Rt.Peritrochateric Metastic Lession (Bone Cancer). Accordintly, the operation was done on 24/03/2010.  The total hospital bill for the operation was Rs. 47,270/-.  I have opted for cashless mediclaim facility and therefore, Deenanath Hospital send the bill of Rs. 47,270/- to MDIndia (TPA) for sanction.  But MDIndia was sanctioned only Rs. 15,000/- stating that the disease was pre-existing, as I have taken claim of my mother for CA Breast (Breast Cancer) in the year 2005 for Rs. 15,000/- as the sum  assured limit of my policy was Rs. 15,000/- in the year 2005-2006 and after that the sum assured is increased from Rs. 15,000/- to Rs. 50,000/-. 

                There are some points in my minds -

1.       The disease can not be treated as pre-existing as my mother suffered from CA Breast in the year March, 2005 and after a considerable period of 5 years, the disease is occurred in the another part of the body.

2.       I have not intentionally increased the sum assured from Rs. 15,000/- to Rs. 50,000/-, but the Insurance Company have compulsorily increased the sum assured from Rs. 15,000/- to Rs. 50,000/- for every mediclaim policy holder.

3.       I have paid the premium for the sum assured of Rs. 50,000/- (minimum sum assured compulsorily decided by the Insurance Company) for my mother from the year 2006-2007 to 2009-2010 i.e. continuously        for 4 years after occurance of CA Breast disease of my mother in the year March, 2005.

4.       As per the Mediclaim Insurance Policy for Individuals, it is stated in Point No. 3 – Any One Illness that “Any one illness will be deemed to mean continuous period of illness and it includes relapse within 105 days from the date of discharge from the Hospital / nursing home from where the treatment was taken.  Occurance of the same illness after a lapse of 105 days as stated above will be considered as fresh illness for the purpose of this policy”.

                So, please suggest the claim of Rs. 15,000/- settled by the TPA is right or wrong? Whether I should go to Ombudsman?

HEMANT - E-mail : hem_san@rediffmail.com