Heard learned counsel for the appellant. None appears for the respondent.
2. This appeal is filed U/S-15 of erstwhile Consumer Protection Act,1986(herein-after called the Act). Hereinafter, the parties to this appeal shall be referred to with reference to their respective status before the learned District Forum.
3. The case of the complainant, in nutshell is that complainant had paid Rs.7150/- as first premium of the insurance to Op No.3 on 14.02.2008 who in turn sent the said amount to OP No.2 who got issued the policy bond called ‘Care First’ a mediclaim policy for sum assured of Rs.3.00 lacks in favour of the complainant. It is alleged inter-alia that before acceptance of proposal the complainant had undergone a medical check up by the doctor of the OPs and found no cardiac problem with the complainant. It is alleged by the complainant that on 22.02.2008 the complainant sustained heart problem and undergone surgery for CAD6/Triple Vessel disease at Usha Fullapuri Cardiac Centre,Hyderabad on 25.02.2008. After operation the complainant demanded the financial assistance from the OPs. However, the OP repudiated the claim on 12.08.2008. Challenging such repudiation, the complaint was filed.
4. The OP No.1 filed written version stating that he is a third party administrator and has been appointed by the insurance company concerned for speed settlement of the claim raised by the policy holder and as such OP has to indemnify. It is also averred that after scrutiny of the claim, they have repudiated the same because of the exclusion clause 8E(iv) and 6B & 6C. Therefore, they have no deficiency in service on their part.
5. After hearing both the parties, learned District Forum passed the following order:-
Xxxx xxxx xxxx
In the above facts and circumstances, we come to a conclusion that the complainant’s case has no merit which needs to be dismissed. In result, we dismiss the case of the complainant.”
6. Learned counsel for the appellant submitted that learned District Forum has committed error in law by not considering the written version filed by the Ops with proper perspectives. According to him as per their doctor, the complainant has been examined and found that the complainant was having pre-existing disease and further he submitted that he has paid the premium Rs.7150/- but there is delay of two days of the commencement of the policy and he suffered cardiac arrest and accordingly got admitted in hospital and after discharge he submitted the medical report for settlement of the claim but learned District Forum, without considering all these facts has repudiated the claim. Therefore, he submitted to set-aside the impugned order by allowing the appeal.
7. Considered the submission of learned counsel for the appellant, perused the DFR and impugned order.
8. It is clear that the complainant has purchased the Mediclaim policy but clause-8 E(iv) of the policy shows that if within 3 years of waiting period from the date of commencement of policy, the policy holder suffered from the diseases, complainant can not claim any reimbursement in this regard including for the disease Angiographies etc. In the instant case complainant already suffered from cardiac problem and underwent the treatment for cardiac disease just after 3 days of the policy commenced. Since, there is exclusion clause-8 E(iv) and the case is covered under exclusion clause, we are of the view that the complainant is not rightly covered under the policy.
In view of aforesaid analysis, we do agree with the finding of the learned District Forum which is affirmed and the appeal stands dismissed. No cost.
Free copy of the order be supplied to the respective parties or they may download same from the confonet or webtsite of this Commission to treat same as copy of order received from this Commission.
DFR be sent back forthwith.
