Present (1) Nisha Nath Ojha,
District & Sessions Judge (Retd.) President
(2) Smt. Karishma Mandal,
Member
Date of Order : 31.03.2017
Nisha Nath Ojha
- In the instant case the Complainant has sought for following reliefs against the Opposite party:-
- To direct the opposite parties to pay Rs. 3,66,240/- ( Rs. Three Lack Sixty Six Thousand Two Hundred Forty only )as the expenditure incurred during stay in Hospital.
- To direct the opposite parties to pay Rs. 1,20,000/- ( Rs. One Lack Twenty thousand only ) for mental torture.
- To direct the opposite parties to pay Rs. 12,000/- ( Rs. Twelve Thousand only ) as litigation costs.
- The facts of this case lies in a narrow compass which is as follows:-
The complainant has asserted that he has taken Medi Claim policy named as PNB oriental Royal Medi Claim vide annexure – 1, 2 and 3 which was effective from 15.11.2011 to 14.11.2012. the aforesaid policy covered the risk of five Lacks and Mrs. Usha Jha was named as nominee of the complainant.
The further case of the complainant is that the complainant never claimed any expenditure during the first premium which was from 14.11.2010 to 13.11.2011 as during those days the complainant was never suffering from any disease. The complainant for the sake of safety was admitted for routine health checkup in Medanta Medi City Hospital situated in Gurgaon, Haryana on 21.12.2011 and was discharged on 24.12.2011, wherein he was diagnosed as type II diabetes mellitus, Hypertension, Dyslipidaemia, Coronary Artery Decease, Double Vessel Decease as will appear from annexure – 4 as well as discharge summary which is annexed on page 23 of the complaint petition.
It is the case of the complainant that his claim has been repudiated by the opposite party no. 2 vide annexure – 4 dated 11.05.2012 on the ground that the aforesaid disease was pre – existing.
It is the case of the complainant that the complainant had got good health without having any problem of Hypertension BP and the same decease was not earlier but on the ground of pre – existing decease the opposite party no. 2 had rejected the claim of the complainant.
It has been further asserted that after discharge from the Hospital the complainant has filed full detailed expenditure which was to the tune of Rs. 3,66,240/- but insurer opposite party with malafide intention repudiated the claim.
It has been further asserted that the medical certificate filed by the Doctor treating the patient has written in column – 8 that there is no any pre – existing decease.
On behalf of opposite parties written statement has been filed in which the policy documents have been admitted. In Para – 8 of written statement following facts have been asserted, “that as the complainant was admitted Medanta on 21.12.2011 with the final diagnosis as type 2 Diabetes Mellitus, Hypertention, Dyslipidaemia, Coronary Artery Disease, which are not covered in second year of policy as per exclusion clause 4.1 of the policy terms and conditions.”
We have heard both the parties in detail.
It have been submitted by the learned counsel for the complainant that he had gone to Hospital for routine checkup but the Hospital has charged the bill of Rs. 3,66,240/- for only wrong full gain.
From bare perusal of the Hospital documents it is crystal clear that he was unnecessarily admitted in ICU and charged Rs. 8,000/- and Rs. 6,000/- per day for two days which shows that he was admitted in ICU with malafide intention.
It has been further submitted that from bare perusal of different documents filed by the complainant as well as the insurance company it is crystal clear that the insurance company has been failed to establish link between any pre – existing decease and the routine checkup.
Heard the parties.
The complainant has asserted that he was only admitted in the Hospital for routine checkup but the Hospital in order to give more money had admitted in ICU and has charged Rs. 3,66,240/- on different pretext which is beyond the capacity of the complainant.
We have gone through the entire record of the case and found that there is no material to prove that the aforesaid decease diagnosed by the Hospital were pre – existing.
The Hon’ble national Commission in citation reported in III (2012) CPJ 322 (NC) (National Insurance Company Ltd. Vrs. Girin R. Shah) have been pleased to hold that it is necessary to prove link between the pre – existing decease with a recent diagnosis, if any.
The report of the Hospital does not suggest that the aforesaid decease were present in the complainant at the time of issuing insurance policy.
Hence we find and hold that by rejecting the claim of the complainant the opposite party no. 1 and 2 have committed serious deficiency.
Hence we direct the opposite party no. 1 and 2 to pay Rs. 3,66,240/- ( Rs. Three Lack Sixty Six two Hundred Forty only )to the complainant which is the expenditure incurred in Hospital within the period of two months from the date of receipt of this order or certified copy of this order failing which opposite party no. 2 will have to pay 10% interest on the said amount of Rs. 3,66,240/- ( Rs. Three Lack Sixty Six two Hundred Forty only )till its final payment.
Opposite party no. 1 and 2 are further directed to pay Rs. 10,000/- ( Rs. Ten Thousand only ) to the complainant by way of compensation and litigation costs within the period of two month.
Accordingly the complaint stands allowed to the extent referred above.
Member President
