[Resolved]  Cigna TTK Health Insurance — cashless denied, then reimbursement also denied (claim amount rs.2, 46, 301) for the pro health plus policy with claim#19373894

Apr 12, 2019

Updated by pratyaksh27 The State Consumer Dispute Redressal Forum enumerated guidelines which help in determining pre-existing disease:

-The Disease means a serious derangement of health or chronic deep-seated disease frequently one that is ultimately fatal for which an insured must have been hospitalized or operated upon in the near proximity of obtaining the mediclaim policy.
-Such a disease should not only be existing at the time of taking the policy but also should have existed in the near proximity. If the insured had been hospitalized or operated upon for the said disease in the near past, say, six months or a year he is supposed to disclose the said fact to rule out the failure of his claim on the ground of concealment of information as to pre-existing disease.
-Malaise of hypertension, diabetes, occasional pain, cold, headache, arthritis and the like in the body are normal wear and tear of modern day life which is full of tension at the place of work, in and out of the house and are controllable on day to day basis by standard medication and cannot be used as concealment of pre-existing disease for repudiation of the insurance claim unless an insured in the near proximity of taking of the policy is hospitalized or operated upon for the treatment of these diseases or any other disease.
-If insured had been even otherwise living normal and healthy life and attending to his duties and daily chores like any other person and is not declared as a diseased person as referred above he cannot be held guilty for concealment of any disease.
-Disease that can be easily detected by subjecting the insured to basic tests like blood test, ECG etc. the insured is not supposed to disclose such disease because of otherwise leading a normal and healthy life and cannot be branded as diseased person.
-Insurance Company cannot take advantage of its act of omission and commission as it is under obligation to ensure before issuing medi-claim policy whether a person is fit to be insured or not.
-Claim of any insured should not be and cannot be repudiated by taking a clue or remote reference to any so-called disease from the discharge summary of the insured by invoking the exclusion clause or non-disclosure of pre-existing disease unless the insured had concealed his hospitalization or operation for the said disease undertaken in the reasonable near proximity as referred above.
-Day to day history or history of several years of some or the other physical problem one may face occasionally without having landed for hospitalization or operation for the disease cannot be used for repudiating the claim.
-Non-disclosure of hospitalization/or operation for disease that too in the reasonable proximity of the date of mediclaim policy is the only ground on which insured claim can be repudiated and on no other ground.

Apr 13, 2019

Updated by pratyaksh27 Hello,

My Policy# PROHLR[protected] and the contact Number is [protected]

Apr 15, 2019

Updated by pratyaksh27 I haven't recieved any call yet!!!

Apr 15, 2019

Updated by pratyaksh27 Hello Cigna TTK Health Insurance Customer Care,

I dropped an email to Cigna TTK Grievance Cell also explaining the entire scenario with medical proofs, but I haven't received any update on this.

Thanks,
Pratyaksh

Apr 17, 2019

Updated by pratyaksh27 Hello,

It's the last time I'm raising this concern, will anyone call me from Cigna TTK Grievance team?