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  1. Insurance claim for genetic disorders: Delhi HC says companies can’t deny claim

Insurance claim for genetic disorders: Delhi HC says companies can’t deny claim

The Delhi High Court, in a significant ruling, has said that insurance companies can't deny health insurance to those suffering from genetic disorders.

By: | Published: February 27, 2018 6:35 PM
Insurance claim for genetic disorders, genetic disorders, Delhi High Court, insurance companies, insurance claim, Jai Prakash Tayal, United India Insurance Company Ltd, The Delhi High Court has ruled that the exclusionary clause of ‘genetic disorders’, in the insurance policy, is too broad, ambiguous and discriminatory – hence violative of Article 14 of the Constitution of India.

Suffering from genetic disorders and finding it difficult to get a suitable health insurance policy? Here’s good news for you. The Delhi High Court, in a significant ruling, has said that insurance companies can’t deny health insurance to those suffering from genetic disorders.

Delivering the judgement, Justice Prathiba M. Singh held that “discrimination in health insurance against individuals based on their genetic disposition or genetic heritage, in the absence of appropriate genetic testing and laying down of intelligible differentia, is Unconstitutional.”

The verdict came in the case of Jai Prakash Tayal vs United India Insurance Company Ltd. Tayal had earlier taken a medi-claim policy from National Insurance Co Ltd in 2000, which was later shifted to United India Insurance Company on 10th September, 2004, after which the policy was renewed continuously year to year without break till 10th September, 2012. Tayal, who was suffering from Hypertrophic Obstructive Cardiomyopathy, was hospitalised earlier also, but his claims were honoured and payments were made by the insurance company.

Tayal was again hospitalised for treatment on 27th November, 2011 and was discharged on 30th November, 2011. He made a claim for an amount of Rs 7,78,864. The said claim, however, was rejected by the insurance company on the ground that “genetic diseases are not payable as per the policy, genetic exclusion clauses.”

Tayal filed a case in the Trial Court, which ruled in his favour, holding that an insurance policy has to be renewed on the existing terms and conditions, and at the time of renewal, fresh clauses and exclusions cannot be added. The Trial Court held that no advance notice was given to the plaintiff and that some new clauses have been added to the policy. The Trial Court thereafter held that there cannot be a discriminatory clause against those persons who suffered from genetic disorders and they are entitled to medical insurance. The Trial Court decreed the suit for a sum of Rs 5 lakh along with interest of 8% per annum, and rejected the claim for damages of Rs 2,78,864. The insurance company appealed against the Trial Court’s order in August 2017.

Now the Delhi High Court has ruled that the exclusionary clause of ‘genetic disorders’, in the insurance policy, is too broad, ambiguous and discriminatory – hence violative of Article 14 of the Constitution of India. It further directed the Insurance Regulatory Development Authority of India (IRDA) to “re-look at the Exclusionary clauses in insurance contracts and ensure that insurance companies do not reject claims on the basis of exclusions relating to genetic disorders.”

Industry Experts Welcome Ruling

Welcoming the HC ruling, industry experts say that the current construct and design of the standard health insurance policy do keep genetic disorders out of the scope of coverage.

“Customers usually are taken by shock, as such technical fine print is usually complex and hence overlooked, unfortunately, till a claim arises. With advancement in medical science and relatively better availability of data, it is important insurance companies design policies that cover all necessary medical treatment, after the customer has served the time-bound exclusions in the policy. This will ensure coverage is simple to understand and claim too,” says Mahavir Chopra, Director – Health, Life & Strategic Initiatives, Coverfox.com.

We also need to differentiate between congenital conditions and genetic disorders. “Genetic disorders are related to genes, but they may not be present since birth and the insured may not know about it. Congenital is mostly known and is present since birth. As per the regulatory authority, exclusions are in place only for congenital conditions. Breast cancer could be an example where it could have been passed on genetically. However, such conditions can’t be excluded just because they are not congenital. For consumer’s benefits, insurers can list such excluded conditions in the T&C,” advises Biresh Giri, Appointed Actuary, Acko.

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