MEDICAL OPINION VS LEGAL OPINION IN MEDICLAIM CASES

During the last five six years, it has been observed that almost each and every mediclaim has been turned down on one or the other pretext by the insurance companies except a few in which claimant manages to get the claim by providing warmth to the dealing man The claim is invariably rejected on the plea of pre-existing disease and for concealment of fact at the time of filling up the prescribed  form. This has also been seen by the consumer forums that the questionnaires of the said form are framed in such a manner that there cannot be any straight answer in yes or no whereas the instructions are to reply in yes or no only. At times such forms are filled up by the agents of the insurance company who aims at bringing more and more cases/clients and they assure the insured to relax for everything and thousands of people are made to believe that they are totally secured once they have opted for mediclaim policy In this process, whatever information has been given by the insurer,  at the time of settling the claim is said to be untrue by the insurance company and claim is rejected for giving wrong statement and concealment of material fact The claim made against whatever disease is said to be pre-existing at the time of giving information through form filled If there is cough and cold at any point of time ,it is considered lungs problem pre-existing judging  it the symptoms for the said disease Uneasiness in  breathing  for any simple reason  becomes heart ailment .  If hospital writes in discharge summery patient having any problem for the last one or two years, any simple pain is co-related with some major disease without having any records of tests and diagnosis etc Generally patient at the time of admission is asked several questions about his health which he replies in casual manner and that statement is recorded in the discharge summery by the hospital .this is actually the statement of the patient and not the findings of the hospital on the bases of tests .The real findings are the diagnosis made by the doctors and medicines prescribed Insurance companies made use of such statements in their favour to reject the genuine claims Apex court took a note of this and found consumers deprived of their claims, hence held in its judgement-such summery from the hospital cannot be treated as cogent proof for declaring the disease pre –existing unless proved by medical tests or medicines taken in past for the said disease having knowledge of the same.Supreme court in the matter between Asha Rani Goyal Vs National insurance company in 2002 categorically denied to admit such statement taken from the patient at the time of admission as an authentic evidence to the fact of pre-existing disease

                                    However insurance companies do take medical opinion by the doctors on their panel in order to know whether any claim case can be treated as case of pre existing disease or not and doctors on panel on the bases of their experience in the field and looking into the case history ,medicines prescribed and also some investigation from the reliable sources give their opinion Recently it has been noticed by the consumer forums that doctors on panel with the insurance companies are going beyond their area of expertise and are giving legal opinion instead of medical opinion

                                    In one such case in the matter of Dr Satya Paul Vs National Insurance Co. Ltd,claim of the complainant was rejected on the plea of pre-existing disease attracting provisions of clause 4.3 of the terms of insurance While going through the terms and conditions of mediclaim policy, it was the opinion of the consumer forum that clause 4.3 is applicable in the cases where disease is pre-existing. Insurance company in the present case all the time referred to this clause stating that treatment was taken in the first year of the policy but never mentioned as to how it was pre-existing .Consumer Forum pinpointed the opinion of doctors on panel of insurance company which court found just not medical opinion.Dr`s report states as hereunder –

                                    Diagnosis immature senile cataract, left-right. Mrs Sharma in this case has undergone cataract surgery within first year of the policy, Such treatment is specifically excluded vide exclusion clause 4.3 of the policy Hence this claim is not admissible as per the terms of the policy  Further another Dr x has also given medical opinion as under –

                                    This case in which patient was admitted in the hospital with IMSC for phacoemulification was justified for hospitalization But since policy of the claimant is in the first year ,so according to the terms and conditions of medi-claim policy,this comes under exclusion clause ,so case should be closed as no claim.All other papers in the file are in order and are of diagnosed disease.

                                    Both the doctors have nowhere said that this disease was pre-existing They have not mentioned about any previous history or any report from any doctor ,from any hospital or referred to any medicines taken by the patient for the said disease before undergoing for the operation of the diagnosed disease Without establishing the disease pre-existing, this clause is not applicable at all.Apart from this ,it is noted by the consumer forum that the doctors on panel are instead of giving medical opinion,are giving legal interpretation to the clauses which is actually to be done by the department concerned.This is the quasi-judiciary function to be done by either the legal department or personnel and administrative department and doctors on panel are in no way authorized to touch this area.It is the company to see whether the claim is tenable or not while interpreting the rules.Here it is seen that doctors are making legal opinions and interpreting the terms and taking the decisions also which doctors on panel are not supposed to do.Doctors are to give their professional/medical opinion about the disease,about the diagnosis,about the medicines taken,about the history of the ailment on the bases of their experience in the medical line Both the doctors have done nothing on their part and virtually decided the claim not tenable though they are no authority to do so. It was the observation of the forum  that the words are put into their mouth and they have tried to aunthenticate the decision by a professional opinion.A suggession has been made for the doctors on panel by the Consumer  forum to limit their opinion to their role and maintain the grace of the noble profession of doctors

                                   

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                                                                                                DR PREM LATA

                                                                                                Member Consumer Forum

                                                                                                 North West.