DISTRICT CONSUMER DISPUTES REDRESSAL FORUM (CENTRAL)

MAHARANA PARTAP BUS TERMINAL: 5^th  FLOOR.

KASHMERE GATE DELHI.

No. DF / Central/ 2015

Sanjay Jain

S/o D. P. Jain

R/o M-34, Navin Shahdara, Delhi-110032

                                                                                          ..........Complainant

Versus

1. Karvat Healthcare services Pvt. Ltd

304, 3^rd Floor, Ashish Coplex,

New Rajdhani Enclave, Preet Vihar, Delhi-110092

2. Dedicated Healthcare Services (TPA) India Pvt. Ltd

1205 , Chitranjan Tower,

43, Nehru Place, New Delhi-110019

                                      ..........Respondent/OP

BEFORE

SH. RAKESH KAPOOR, PRESIDENT

SH. S. N. SHUKLA, MEMBER

ORDER

Per Sh. RakeshKapoor, President

    The complainant is holder of a mediclaim policy from the OP which was valid for the period 31.1.2011 to 30.1.2012. it is alleged that on 21.1.2012 he was hospitalized and an angioplasty was performed on him at G. B. Pant Hospital.  . He was discharged on 7.1.2012. A   second operation was performed on him at Walia Nursing Home Laxmi Nagar , Delhi. It is alleged  by the complainant  that  the expenses incurred by him on  the treatment were not reimbursed to him which led the complainant to approach this forum.

The OP has contested the complaint and has filed a written statement.

It has denied any deficiency in service on its part and has claimed that the complaint is misconceived and is liable to be dismissed.   It has justified  non-payment of the  claim to the  complainant  and has claimed that it had acted within the terms and conditions of the policy of insurance according to which expenses incurred on pre-existing disease were not payable.

Para 4 of the reply on merits of the written statement  is  relevant for the purposes of the disposal of this complaint and reads as under:-

4.That as per the terms and conditions no. 4.1 of the policy is as under:-

“All diseases/ injuries which are pre-existing when the cover incepts for the first time. However, those diseases will be covered after two conditions or more claim free policy year depending upon the specific exclusions mentioned in the policy certificate based on the medical condition at the time of proposal.  This exclusion shall not be applicable in roll over cases, where the insured person has been covered under any individual mediclaim policy, the two year or more waiting period will be applicable depending upon the current medical condition”.

That as per the discharge summary of Mr. Sanjay Jain a known case of Diabetes, hypertension, Dyslipdemia and admitted with C/O Retrosternal Chest Pain since a month radiating to both arm O/L Cag S/O LCx-After major Om 80% stenosis, LAD and RCA as DOI -30/01/2011 and as this the first year of the policy the said ailment cannot exist in a span of one year hence the claim is not payable.

That as per condition no. 4.3 of the policy terms and conditions is under:-

“During the first 24 months of the operation of the policy the expenses incurred on treatment of diseases such as cataract, beign prostatics Hypertrophy , Hysterectomy arising out of Menorhagia, Hernia , Hydrocele, Congenital Internal Diseases, Fistula in anus, Chronic fissure in anus, piles, pilonidal sinus, sinusitis , stone diseases of any site, benign Lumps growths in any parts of the body, CSOM (Chronic Suppurative Otitis Media), Joints replacements of any kind unless arising out of accident, surgical treatment of tonsils, adenoids and deviated nasal septum’s and related disorders are not payable.” This condition 4.3 shall however, not apply in case the insured person has been covered under individual mediclaim insurance scheme with any of the Indian Insurance Companies for the continuous period of 24 months without any break subject to underwriting terms and conditions at the time of roll over of policy.”

   We have heard arguments advanced at the bar and have perused the record.

    The learned counsel for  the OP has drawn our attention to this fact that the mediclaim policy purchased by the complainant was effective for the period 31.1.2011 to 30.1.2012. He has then taken us through the medical record of the complainant prepared at G. B Pant Hospital according to which the complainant was a known case of diabetes and hypertension.  The record further shows that the complainant  had  history of retrosternal chest pain a month back before admission in the hospital on 2.1.2012.He has  therefore contended that the complainant had a pre-existing disease at the time the policy of insurance was  purchased by the complainant. He has referred to clause 4.1 read with clause 4.3 of the policy purchased by the complainant and has contended that the  OP was justified in rejecting the claim lodged by the complainant in the present case.   We have considered the contentions  of the OP with  which we do not agree. The complainant had suffered from a heart ailment and an angioplasty procedure was undergone by him. There is no evidence on record that the complainant was a patient of heart disease at the time of inception of the policy on 31.1.2011.  There is no evidence that the complainant had been admitted in the hospital earlier to his hospitalization for treatment of the aforesaid disease. We have seen the proposal form a copy of which has been made available by the OP. There is no evidence that the complainant had made any misstatement about the state of his health at the time of the purchase of the policy. We are, therefore, of the considered opinion that the repudiation of the claim of the complainant on the basis that the complainant was suffered from a pre-existing disease was not justified and was an act of deficiency on the part of the insurance company.  We, therefore, direct M/s National Insurance Company (OP3) as under:-

1. Pay to the complainant a sum of Rs. 1,00,000/- (the assured amount) along with interest @ 10 % p.a. from the date of institution i.e. 21.5.2012 till payment.

2. Pay to the complainant a sum of Rs. 5,000/- as cost of litigation.

               The above amount shall be paid by OP3 to the complainant within 30 days from the date of this order failing which  OP3  shall be liable to pay interest on the entire awarded amount @ 10% per annum from the date of this order till the date of payment. If OP3 fails to comply with the order within 30 days, the complainant may approach this Forum u/s 27 of the Consumer Protection Act.

Copy of the order be made available to parties free of cost as per law.

    File be consigned to R/R.

    Announced in open sitting of the Forum on_____________

    ( S N SHUKLA )                ( RAKESH KAPOOR )

          MEMBER                   PRESIDENT