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Denying Claim Amount Over Med Terminology Costs Insurance Company Dear

| Updated: January 12, 2024 12:55

In a queer nomenclature gimmick, insurance companies can deny claim for a heart attack death if it doesn’t match their term. How does it matter if a person dies of sudden cardiac arrest or myocardial infarction? But, an insurance company can use this technical medical difference to deny the claim.

A private insurer, who rejected a claim citing these technicalities, recently got a rap from the Bharuch Consumer Commission which directed the company to pay the coverage of a home loan of Rs 12.36 lakh to a woman who has been widowed at 25, after the death of her husband due to heart attack.

According to the case details, Bharuch woman Payal Patel’s husband Dipesh died of cardiac arrest on November 27, 2022. He had taken a home loan of Rs 15 lakh from a private bank for 25 years in 2021. He also took a five-year insurance for the loan in March 2021 by paying five years of premium in advance.

After his death, Payal filed the claim with the insurance company but it was rejected on April 17, 2023, on the grounds of ‘type of heart attack’. The insurance company claimed it was not liable to pay the loan amount as Dipesh did not die of myocardial infarction (first heart attack with specific severity and symptoms).”
When Dipesh died, EMIs totaling Rs 12.36 lakh were pending on his loan for which Payal had submitted the claim.

Payal then filed a complaint with the Bharuch Consumer Disputes Redression Commission (CDRC) which lambasted the company for citing technical reasons and directed it to pay the pending home loan as per the policy purchased by Dipesh to the bank.

The commission also rejected the insurance firm’s arguments about MI. There is no such fact mentioned in the policy terms, it said. “Policy has defined accidental death as an accident or accidental means a sudden, unforeseen and involuntary event caused by external, visible and violent means. As per this condition, the death is due to sudden cardiac arrest. And so, it should be included as accidental death,” the forum observed.

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