CONSUMER DISPUTES REDRESSAL FORUM – X
GOVERNMENT OF N.C.T. OF DELHI
Udyog Sadan, C – 22 & 23, Institutional Area
(Behind Qutub Hotel)
New Delhi – 110 016
Case No.756/2008
Shri Bhim Arora,
S/o Late R.K. Arora,
B-99, Ground Floor,
Prashant Vihar,
Rohini Delhi-110085. ………. Complainant
Vs.
- IFFCO-TOKIO
General Insurance Company Limited
Through its Managing Director/ Director
Having its registered office at
34, Nehru Place,
New Delhi-110019.
- Paramount Healthcare Management Pvt. Ltd.
F-90/12, Near ESI Hospital,
Okhla Industrial Area,
Phase-I, Delhi-110020. …………..Respondent
Date of Order: 06.10.2016
O R D E R
Ritu Garodia-Member
The complaint pertains to repudiation of medi claim by OP insurance company.
A group medi claim insurance (Floater) policy bearing no. 52042877 was purchased from the OP Company. The complainant’s father was admitted on 24.05.2007 in Saroj Hospital and Heart Institute. He expired on 08.06.2007. The medical reports, death summary along with the bill are annexed with the complaint. Thereafter, a claim was filed with OP Company which was repudiated on the ground of pre-existing ailment. Complainant has also annexed a certificate by treating Hospital stating that the insured was having cough expectoration and was never hospitalized for such complaint. He was taking treatment from local dispensaries and doctors.
OP insurance company in its reply has stated that as the group medi claim was purchased by a company, the complainant is not a consumer. It is stated that the medical records and documents reveal that the insured was having cough expectoration for the last 2-3 years and was being treated by various doctors. Moreover, the insured was a known case of COPD (Chronic Obstruction Pulmonary Disease). The said disease cannot occur in a day and must be having a long history. Both these disease falls within the category of pre-existing disease and OP is well within its right to repudiate the said case.
We have perused the documents, and the certificate by treating doctors on record. The insurance cover and follow-up hospitalization is admitted by both the parties. The death summary reveals that the death occurred due to respiratory failure, The insured was having cough expectoration for 2-3 years and was being treated by various local doctors. The dictionary defines cough expectoration as “to eject or expel matter, as phlegm, from the throat or lungs by coughing or hawking and spitting”. In layman’s language, cough expectoration is described as simple coughing.
The affliction of cold, cough, headache are normal in day to day life and cannot be termed as disease. These are life style maladies which are treated by standard medication on day to day basis.
The complainant’s coughing was treated by various local doctors and by taking general medicine for year like any normal reasonable human being. No doctor had prescribed him any test or medication which has led to the hospitalisation.
National Commission in Life Insurance Corporation of India vs. Charanjit Kaur Vol-IV (2011) CPJ 373 (INC.) has concurred with order of District Forum relevant portion of which are reproduced :
The cause of death has been given Jaundice but he opposite parties are not sure whether jaundice was due to infective hepatitis or other illnesses like stones or cancer. The various other conditions can produce Jaundice and the Jaundice is also seen in children and neonates where the case may be haemolytic. In the present case no such evidence has been produce to the effect that cause of death had any connection with the taking of liquor. No material has been produced by the opposite parties to prove that Jaundice was due to taking of liquor by the deceased during his lifetime.
OP has not produced any evidence as to the death being caused by the coughing of the complainant.
OP has also alleged that as the insured was a known case of chronic obstruction pulmonary disease, it must have been present for a long time in complaint before inception of the policy. However, such presumptions has not been substantiated by any evidence from OP. The vague allegations levelled by OP regarding the pre-existing disease in its pleading shows that the insurance company will repudiate the matter on any ground without any proof.
Hence we find OP guilty of deficiency in service and direct to OP to refund Rs. 1,32,377/- which is bill amount by Saroj Hospital along with interest @ 9% p.a. from the date of claim till payment. We also award Rs. 5,000/- towards harassment, mental agony, physical inconvenience inclusive litigation expenses.
Let the order be complied with within one month of the receipt thereof. The complaint stands disposed of accordingly.
Copy of order be sent to the parties, free of cost, and thereafter file be consigned to record room.
(D.R TAMTA) (RITU GARODIA) (A.S YADAV)
MEMBER MEMBER PRESIDENT
