Mr. Deepak was a loyal premium payer for a long time before he was diagnosed with respiratory failure at Suvichar Hospital, Nashik. However, after his demise, his family submitted all the required documents, but the insurance company denied the claim stating that the disease was not covered under critical illness. Imagine the situation of the family members of Mr. Deepak at this point. The cause of death, coronary artery disease (CAD), and its sequelae were expressly stated by the Civil Hospital Nashik after conducting the post-mortem. However, the findings of the post-mortem were not gone through by RI, and the genuine liability of the company covered under the policy was denied, stating that the condition did not meet the criteria of critical illness.
The Complainant mentioned that they had taken the policy when acquiring the housing loan to protect the loan amount in case of a personal accident or critical illness. Hence, denying the insurance claim is unacceptable, as it should not have occurred under any circumstances.
RI observed that the insured’s above diagnosis and cause of death, i.e., Coronary Artery Disease mentioned in the PM report, does not come under the purview criteria for the critical illness, medical and surgical procedure as specified in the policy terms and conditions. As a result, the insured’s claim was rejected because the benefit needed to be covered as per the policy terms and conditions.
At this point, the deceased’s family contacted Insurance Samadhan and we started to analyze the case. In our research, we found out that the criteria of critical illness, such as CAD, which can lead to heart failure, were met according to the findings of the post-mortem. The IRDA has defined critical illness, which includes severe medical conditions such as heart attack, under the standardization of health insurance in India. Therefore, the full amount of the claim was requested from the forum to intervene and settle the complaint.
The post-mortem findings revealed 90% blockage in the right coronary artery and around 80% in the left coronary artery. These complications are considered to fall under one or more critical illnesses listed in the policy cover, such as Myocardial Infarction or end-stage Liver Disease (Fatty Liver, as stated in the hospitalization records of Suryoday Hospital). As a result, the forum concluded that the claim is eligible for payment under the policy’s listed critical illness.
Insurance Samadhan filed a complaint with the ombudsman’s office, which ordered the insurer to pay the full amount of INR 7,62,000 towards the full and final settlement of the complaint. Our expertise and guidance helped Mr. Deepak’s family to get what they deserved.
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