Kathmandu. When it comes to life insurance or health insurance, most people try to hide as much as possible if they have a pre-existing disease. In the insurance proposal, it is customary to draw a line saying that there is no in the choice of whether or not there is a disease in the option of health-related questions and hand over the proposal form to the agent.
Most of the agents we have are not professional, so instead of advising the insured not to hide any disease, they deliberately encourage the insured to mention or lie in the insurance offer form.
In normal circumstances, even if nothing happens, there is a big calamity at the time of claiming death claim or medical expenses, the insured should be deprived of the benefits of the policy.
While filling up the proposal form, the insured or proposer should inform the insured in a transparent manner without lying or concealing any details related to any disease, treatment related details or taking of medicines. In doing so, the insurer cannot deprive the insured of the claim amount on the grounds that the claim is already withheld at the time of payment of the claim.
Nepal Beema Authority (NEA) has decided to pay the claim amount to the dependents of the insured family members after the death of the insured person.
Background:
LIC Nepal had issued a term insurance policy of Rs 200,000 in the name of Gunjana Sehgal on April 2, 2020. He later died of a heart attack. After the death, the family members of the insured applied to the insurance company for payment of the death claim.
However, LIC Nepal did not pay the death claim claim, claiming that the insured’s death was due to chronic disease. In protest, Bhaskar Sehgal, a member of the deceased, filed a complaint at the NRA on July 9, 2080.
During the investigation of the complaint, the Authority asked the questions asked in the personal health history of the insurance proposal form, did you have any disease in the last five years that required treatment for more than a week? Did you consult a doctor? She had registered a proposal form stating that she was not in question.
According to the medical examination report of Kist Medical College, Lalitpur, where the insured Sehgal received regular treatment on January 23, 2022, it was revealed that the insured had been suffering from diabetic mellitus for the past three years, rheumatoid arthritis for the last thirty years and HTN for ten years.
Authority:
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In the insurance proposal form, the insured had lied and concealed the information that she was being treated for rheumatism, high blood pressure and diabetes. Although the information about these three diseases was concealed, the hospital treatment documents and death declaration at the time of death mention that pneumonia was the main cause of death. For this reason, the judicial bench of the Insurance Authority ruled that the claim should be paid as the insured died due to other reasons and not due to the hidden disease.
According to the authority, the emergency card of Kist Medical College, Lalitpur on January 26 and January 26, 2020, was identified as pneumonia and in the Patient History section, it was mentioned that he had HTN DM-T@ i.e. high blood pressure and diabetes. In addition, the insured had not been able to obtain documentary proof confirming the disease before the commencement date of the insured’s insurance on April 20, 2020.
Apart from this, considering the immediate cause of death of the insured, it has been confirmed that the cause of death of the insured was pneumonia and since it has been found that the insured has been suffering from diabetes for the last three years, rheumatoid arthritis for the last thirty years and high blood pressure for the last ten years, the contention of the insured that there is no need to pay the claim does not fit.
If the insured obtains death due to such a disease by concealing the disease known to him before taking the insurance and not disclosing it to the insurer, it is deemed to have been contrary to the principle of good faith of the insured. In this claim, there was no situation of death of the insured due to an undisclosed disease before the insured, so the authority ruled in favor of the insured and paid the insurance amount to his family members.
