IMPORTANT POINT
Insurance company cannot repudiate any claim against to the rules issued by IRDA.

V.K. Jain, Presiding Member—The first issue involved in this revision petition is as to whether the disorder, from which the son of the complainant suffered, was a congenital or a genetic disorder. The petitioner has filed opinion from Prof. Dr. Alka Deshpandey, stating therein that genetic and congenital are two different groups of disorders, are not used as synonyms and are not interchangeable. She has also opined that all congenital disorders / defects are not genetic disorders. In the Discharge Summary, issued by MAX hospital, the disorder of the son of the complainant was described as a known case of congenital nephritic syndrome. At the time of discharge, the patient was advised management of Congenital Nephrosis. However, Dr. C.H. Asrani in his opinion dated 19.2.2014, observed that the child had congenital nephrotic syndrome, which was an inherited disease (genetic). Even Prof. Alka Deshpandey whose opinion the petitioner has filed, pursuant to the liberty granted by this Commission vide order dated 22.5.2018, has conceded in her report that some congenital disorders / defects can also be genetic disorders, when she said that all congenital disorders / defects are not genetic disorders. This is not the opinion of Dr. Alka Deshpandey that no congenital disorder can be genetic disorder. Though, the petitioner has also placed on record a certificate from one Dr. Kaustubh Kamat issued on 08.6.2018, the said document has been filed without any permission of this Commission since the petitioner was permitted only to file an opinion in support of its contention that a congenital disorder is altogether different from a genetic disorder. More importantly, the report of Dr. C.H. Asrani was filed by the petitioner itself and Dr. C.H. Asrani having stated that the child had congenital nephrotic syndrome, which was an inherited disease (genetic), the petitioner is precluded from disputing that though the child was suffering from a congenital disorder, the said disorder was also a genetic disorder. In other words, disorder was such which could also qualify as a congenital disorder.

2. Vide its order dated 26.2.2018, passed in RFA No. 610 of 2016 & CM Nos. 45832/2017 United India Insurance Company Limited Vs. Jai Prakash Tayal, the Hon’ble High Court of Delhi inter-alia held as under:

1. “Right to avail health insurance is an integral part of the Right to Healthcare and the Right to Health, as recognized in Art. 21 of the Constitution;

2. Discrimination in health insurance against individuals based ont heir genetic disposition or genetic heritage, in the absence of appropriate genetic testing and laying down of intelligible differentia, is Unconstitutional;

3. The broad exclusion of ‘genetic disorders’ is thus not merely a contractual issue between the insurance company and the insured but spills into the broader canvas of Right to Health.There appears to be an urgent need to frame a proper framework to prevent against genetic discrimination as also to protect collection, preservation and confidentiality or genetic data.Insurance companies are free to structure their contracts based on reasonable and intelligible factors which should not be arbitrary and in any case cannot be ‘exclusionary’.Such contracts have to be based on empirical testing and data and cannot be simply on the basis of subjective or vague factors. It is for lawmakers to take the necessary steps in this regard.

4. The Exclusionary clause of ‘genetic disorders’, in the insurance policy, is too broad, ambiguous and discriminatory – hence violative of Art.14 of the Constitution of India;

5. Insurance Regulatory Development Authority of India (IRDA) is directed 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”.

3. Pursuant to the above referred decision of the Hon’ble High Court of Delhi, the Insurance Regulatory Development Authority