It began with a man in his mid-thirties who walked into a tertiary hospital, troubled by blurring of vision, double vision, and a persistent headache on the right side of his head. His eyes betrayed the problem—strabismus and diplopia were evident, pointing toward a neurological disorder. The provisional diagnosis was sixth nerve palsy, and he was admitted for medical management.
During the digital verification interview, the patient recounted his journey. He spoke of symptoms that had haunted him since May of the same year: pain that evolved into redness, glare sensitivity, and eventually double vision. He described how his vision deteriorated step by step—first at long distances, then at medium, and finally at near sight. Weakness on the right side of his body added to his distress. He had undergone multiple MRIs and nerve conduction studies, but none of the reports were shared. Even intracranial pressure values were mentioned only verbally, without documented proof.
The investigation raised red flags. The chronic nature of his complaints suggested a pre-existing neurological disorder. Yet, this history had not been disclosed at the time of policy proposal. Without imaging or specialist documentation, the claim could not be validated as an acute onset. The absence of evidence became as telling as the symptoms themselves.
Clause-based adjudication was clear: pre-existing conditions not disclosed are excluded from coverage. The insurer’s audit trail documented the material non-disclosure, the recurrent nature of the disorder, and the lack of substantiation. Despite the patient’s suffering, the claim could not be upheld.
Learning Outcome
This case highlighted the importance of:
- Digital verification in uncovering symptom chronology.
- Documentation completeness—verbal reports are insufficient for adjudication.
- Clause enforcement—PED exclusions safeguard fairness and audit integrity.
Final Outcome
The claim was repudiated under the PED exclusion clause, with instructions to maintain a detailed audit trail for compliance and transparency.
1. Patient Profile (Proxy Format)
- Age/Sex: Approx. 36 years / Male
- Presenting Complaint: Right eye blurring, diplopia, hemicranial headache
- Provisional Diagnosis: Right sixth nerve palsy
- Management: Medical (Neurology)
2. Verification Summary
- Video Interview Findings:
- Recurrent symptoms since May 2025
- Diplopia, eye deviation, light intolerance, right-side weakness
- ICP values (~25+) reported verbally, no imaging shared
- Documents Reviewed: Consultation papers only; MRI/NCS not submitted
- Hospital Status: Documentation incomplete
3. Clause-Based Observations
- Policy Validity: Active
- PED Suspicion: Chronic neurological disorder with recurrent episodes
- Material Non-Disclosure: No disclosure at proposal stage
- Documentation Deficiency: MRI/NCS missing; ICP values verbal only
4. Final Recommendation
- Clause Invoked: PED exclusion
- Outcome: Repudiated
- Reason: Chronic neurological disorder predating admission; non-disclosure at proposal stage; incomplete documentation
- Action Points:
- Document PED clause application
- Maintain audit trail citing verbal-only ICP and missing MRI/NCS
- Flag for internal PED watchlist