Complainant through Adv. Kasabekar present
Opponents through Adv. Shinde
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Per : Mr. V. P. Utpat, President Place : PUNE
// J U D G M E N T //
(21/08/2013)
This complaint is filed by the insurance policy holder against the Insurance Company, who has wrongly repudiated the mediclaim and caused deficiency in service. The brief facts are as follows,
1] The complainant is a resident of Neharu Nagar, Pimpri, Pune, who is a member of opponent insurance company since 29/4/2011. As per the terms and conditions of the mediclaim policy, he himself as well as his family members are entitled for reimbursement of the medical bills. His daughter was suffering from unspecified inguinal hernia without gangrene. Hence she was admitted in Aditya Birla Hospital, Chinchwad during the period of 3/11/2011 to 6/11/2011. Complainant has paid bill for treatment to the tune of Rs. 32,028/-. Insurance company agreed to reimburse up to Rs. 29,100/- by letter dtd. 1/11/2011. But again by issuing second letter dtd. 5/11/2011, insurance company repudiated the said claim. Hence complainant has issued notice to the opponent and called upon to reimburse the bill of medical treatment. The opponent replied the notice falsely. Hence the complainant has filed present complaint, as there is deficiency on the part of the insurance company. He has claimed medical bill of Rs. 32,028/-, interest on the said amount to the tune of Rs. 6000/-, compensation for mental and physical suffering to the tune of Rs. 20,000/-, cost of the litigation and notice charges to the tune of Rs. 5000/-. The total claim of the complainant is Rs. 63,028.
2] The opponent resisted the claim by filing written version and denied the contents of the complaint. According to the opponent, the complainant and his daughter were member of the said policy, which were started from 29/4/2011. It is also not in dispute that at the request of the complainant, the opponent had issued letter dtd. 1/11/2011 for the reimbursement of medical bill to the tune of Rs. 29,100/-. But subsequently, it was disclosed that the claim of the complainant was excluded under the clause 4(e)(v), hence the said claim was rejected by the opponent. It is the case of the opponent that the claim is rejected as per terms and conditions of the insurance contract. Hence the complaint is not maintainable and it is liable to be dismissed. The opponent prayed for the dismissal of the complaint.
3] After scrutinizing the documentary evidence, which is produced before this Forum, hearing the arguments of both the parties and considering pleadings, the following points arise for my determination. The points, findings and the reasons thereon are as follows-
Sr.No. | POINTS | FINDINGS |
1. | Whether complainant has proved that the opponent has wrongly repudiated the mediclaim of the complainant? | In the affirmative |
2. | What order? | Complaint is partly allowed. |
REASONS :-
4] The admitted facts in the present proceeding are that the complainant and his daughter were member of the insurance scheme, which is made available by the opponent and as per the terms and conditions of the said scheme; the complainant was entitled for reimbursement of the medical bills for himself as well as for his family members. It is also established by the complainant that initially the opponent has issued letter dtd. 1/11/2011 and agreed for the reimbursement of the bill up to Rs. 29,100/-, but subsequently the said claim was rejected by stating that the said claim is excluded, as the treatment taken by the daughter of the complainant was for pre-existing disease. The learned Advocate for the opponent drew my attention to the clause 4(e)(vi). As per the said clause, Congenital conditions/ treatment for Congenital Anomaly is excluded. It reveals from the record that the complainant has asked medical reimbursement for the medical treatment of his daughter and the diagnosis was inguinal hernia. It is significant to note that the medical examination of the complainant as well as his family members was not taken on the date of issuance of the insurance policy. Hence, it can not be said that the disease, which was caused to the daughter of the complainant was existing on the date of policy or prior to the issuance of the policy. The treatment was given to the daughter of the complainant, who was two years old. There is no cogent and satisfactory evidence produced by the opponent to show that the disease was existing on the date of issuance of the policy or prior to that. Hence, I held that the insurance company has wrongly repudiated the clam of the complainant and the complainant is entitled for the reimbursement of Rs. 32,028/-, i.e. medical bill, which was paid to Aditya Birla Hospital. He is also entitled to receive an amount of Rs. 5000/- for pains and sufferings, Rs. 3000/- for cost of the litigation. In the result, I answer the points accordingly and pass the following order,
** ORDER **
1. Complaint is partly allowed.
2. It is hereby declared that the opponents
have caused deficiency in service by wrongly
repudiating mediclaim of the complainant.
3. The opponents are directed to pay to the
Complainant amount of medical bill i.e.
Rs. 32,028/- (Rs. Thirty Two Thousand
Twenty Eight only), an amount of Rs.5,000/-
(Rs. Five Thousand only) towards pains and
suffering and an amount of Rs. 3,000/-
(Rs. Three Thousand only) towards cost of
the litigation within 6 weeks from the date
of receipt of this order.
4. Copies of this order be furnished to
the parties free of cost.
5. Parties are directed to collect the sets,
which were provided for Members within
one month from the date of order, otherwise
those will be destroyed.
