Most health insurance policies in India have a clause that excludes “genetic disorders” as grounds for mediclaim reimbursement. On Monday, the Delhi High Court ruled that this clause is not just ill-defined but also “unconstitutional” and “arbitrary”. The court gave this verdict while dismissing an appeal by United India Insurance Company (UIIC) against a trial court order directing payment of Rs 5 lakh, plus an interest of 8 per cent, to a Delhi resident, Jai Prakash Tayal, who suffers from a rare heart disorder, hypertrophic obstructive cardiomyopathy. The verdict is groundbreaking because it emphasises that “the right to avail health insurance is an integral part of the Right to Healthcare and the Right to Health, as recognised in Article 21 of the Constitution”.
Insurance policies exclude a range of pre-existing diseases from their plans. In 2013, the Insurance Regulatory Development Authority of India (IRDA) issued a set of guidelines that defined a pre-existing disease. The regulatory authority, however, did not define a genetic condition. This, as the Jai Prakash Tayal case shows, goes against the interests of consumers. UIIC claimed that hypertrophic obstructive cardiomyopathy is a rare genetic disorder and thus outside the purview of insurance claims. The court has come down on such reasoning. “The exclusionary clause of genetic disorders is too ambiguous and discriminatory — hence violative of Article 14 of the Constitution,” the court ruled. It observed the term “genetic disorder” was open to a “myriad interpretations” and this lack of clarity is inimical to public policy. This is significant given that several lifestyle diseases that constitute a major part of the country’s health burden today are known to have some genetic manifestation or the other. An all-encompassing definition of “genetic disorder” would rule out patients with cardiac conditions, high blood pressure and diabetes from the purview of medical insurance. This, as the court observed, defeats the very purpose of insurance.
The verdict is also significant in that it recognises that insurance policies are skewed against the patient. The court has asked the IRDA to ascertain whether the string of exclusionary clauses in insurance policies is valid. “The exclusionary list is so long and so broad that almost every ailment could be said to fall under one of the clauses,” the judgment notes. The court’s stress on inclusion and a rights-based approach, in mediclaim, is timely given that the National Health Policy lays much store on insurance-based healthcare.
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