PER SHRI. S.S. PATIL - HON’BLE MEMBER :

1)This is the complaint regarding deficiency in service on the part of Opposite Parties as the Opposite Parties repudiated the health insurance claim of the Complainant on false ground, as alleged by the Complainant. 

2)The facts of the case as stated by the Complainant are that the Complainant has obtained insurance policy bearing No.121800/48/2008/6914/1094565 from Opposite Party No.1. The Complainant was not told about the terms and conditions in respect of pre-existing disease.

3)Under the cover of the insurance policy, the Complainant had gone to Pataya Bangkok Tour. During the stay at Pataya, he suffered an heart ailment, he was hospitalized in Bangkok Pataya Hospital from 06/11/08 to 11/11/08. An angiogram was taken and angioplasty was done on the Complainant during his hospitalization. The Complainant incurred an expenses of Rs.11,36,136/- (7,58,478 Thai Bath, the Thai currency). The Complainant then filed an insurance claim but the Opposite Party No.2 rejected the claim vide its letter dtd.21/05/2009 on the ground of pre-existing hypertension related to the heart disease.

4) The Complainant therefore, has submitted that thus the Opposite Parties have repudiated his legitimate health insurance claim on the ground of pre-existing disease which condition was not communicated to him by the Opposite Parties. Hence, the Opposite Parties have adopted unfair trade practice.  

8) The Opposite Party No.1 has specifically stated that the ailment of the Complainant is directly related to hypertension which was existing since, 1995. Hypertension is pre-existing condition related to diseases including heart and circulatory disorder and therefore, are excluded from coverage of the policy. Finally the Opposite Party No.1 has prayed that the complaint be dismissed with exemplary cost. Though in the written statement the Opposite Party No.1 has referred to Exh. ‘A’, ‘B’ & ‘C’, there is nothing attached with the written statement. Therefore, it is not necessary to take into consideration the contents of these exhibits as evidence as pleaded by the Opposite Party No.1.

9) Thereafter, the Complainant has filed reply to the written statement of the Opposite Party No.1. In this reply, the Complainant has denied all the points raised by the Opposite Party No.1 in its written statement and reiterated his prayers mentioned in his complaint. The Complainant has also filed his affidavit of evidence and written argument wherein he reiterated the facts of his complaint and denied the points raised by the Opposite Party No.1 in its written statement. Opposite Party No.1 also filed its affidavit of evidence and written argument wherein the Opposite Party No.1 has reiterated the points mentioned in its written statement.

10) At the time of oral argument Opposite Party No.1 is absent. He is absent since, June, 2012. There is an ex-parte order against Opposite Party No.2. We heard the Complainant and perused the papers filed by both the parties and our findings are as follows –

The Complainant has obtained a Mediclaim Policy No.121800/48/2008/6914/ 1094565 from the Opposite Party. During the validity of this policy the Complainant was hospitalized in Bangkok Pataya Hospital from 06/11/08 to 11/11/08 for heat ailment. He incurred an expenditure of Rs.11,36,136/- for this hospitalization. The Complainant filed his mediclaim for Rs.11,36,136/- (7,58,478 Thai Bath) with the Opposite Party. But op repudiated the claim on the ground that “the current illness was the result of pre-existing ailments. The Complainant was treated (hospitalized) for Myo Cardial infraction and congestive heart failure. As the Complainant has hypertension since 1995, hyper tension is pre-existing condition all related disease including all heart and circulatory disorder are excluded from the coverage of the policy.”

11) In this respect we carefully examined the copy of the above said policy. The important term mentioned on the face of the policy read as follows -

       “Any pre-existing medical condition/ailment declared/or undeclared, will be excluded from the policy. The coverage provided is subject to details and declaration by the proposer to the company and attached policy workings bearing.”

        Except the above page of the above said policy, no other terms and conditions are produced either by the Complainant or the Opposite Party. As per the above condition, pre-existing medical condition/ailment is excluded from the policy. In the case in hand hyper tension is the pre-existing medical condition/ailment which is excluded from the policy. However, the Complainant (insured) was not hospitalized for hypertension. As per the Opposite Party No.1 any (letter dtd.21/05/2009) the Complainant was hospitalized for Acute ASMI RECENI Congestive heart failure, Gastric bleed. We carefully examined the hospital papers, but the Complainant was not treated for hyper tension. Hence, the repudiation of the Opposite Parties stands irrelevant and not as per the terms and conditions of the policy. In our candid view the Opposite Parties have repudiated the claim of the complaint on wrong ground. Therefore, there is a deficiency in service on the part of Opposite Parties. Both the Opposite Parties are jointly and severally liable for the said deficiency in service and hence, the Complainant is entitled for his mediclaim insurance claim from Opposite Party No.1 as well as compensation for mental agony and cost of this complaint. However, the compensation and cost prayed by the Complainant is exorbitant hence, we pass the order –

O R D E R