BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM (CENTRAL)

MAHARANA PARTAP BUS TERMINAL, 5TH FLOOR,

ISBT, KASHMERE GATE: DELHI-110006

No. DF(Central)/2015/                                                        Dated:

Complaint Case No.154 of 2014                        

Sh. Kamal Mohan Mehta

S/o Late Sh.Raghunath Mehta

R/o B-72, Shivaji Road, Subhash Vihar

North Ghonda,

DELHI – 110 053.                                                                   Complainant

Versus

M/s United India Assurance Co. Ltd.,

Through its Authorized Person/Managing Director

24-15, Bharat Ram Road, Darya Ganj

New Delhi – 110 002                                                  Opposite Parties

ORDER

Complaint under  Sec.12 of the CPA 1986 as amended upto date

Per Sh. Rakesh Kapoor, President

          It is alleged by the complainant that he had purchased an Individual Mediclaim Policy from the OP on 24.9.2005 and had been renewing the same year after year.  The last renewal was done w.e.f. 6.2.2014 to 5.2.2015 for a sum of Rs.4,00,000/-.  He had also purchased a personal accident policy which was also renewed upto 5.2.2015.  It is also alleged that on 4.2.2014 the complainant had met with an accident. He was taken to his home and was admitted to Sir Ganga Ram Hospital on 7.2.2014 from where he was discharged on 13.2.2014.  He had incurred a sum of Rs.1,98,302/- on hospitalization besides spending a sum of Rs.60,000/- on medicines etc.  He had lodged a claim with the OP which was not settled.  Hence the complaint.

     The OP has contested the complaint and has filed a W.S. It has denied any deficiency in service on its part and has claimed that the complaint is liable to be dismissed.  Para 3 of the preliminary objection of the W.S. is relevant for the purposes of the decisions of this complaint and is reproduced as under:-

       3. That the contract of the insurance is a contract of utmost good faith and he insured is required and expected to disclose the true facts and information without concealing any material facts.  That complainant had failed to disclose the material facts rather concealed the same with the answering respondent by not disclosing the fact that the insured was suffer from and a known case of Low Back Pain Since from the last 10 years and said problems is pre-existing one since from the period of one year and is having exclusion of 2 years.  The present policy was Inception Ed on 24.09.2005.  As per the policy conditions this claim comes under exclusion 4.1 so this claim is not payable therefore the claim was repudiated and intimation to the said effect was given vide letter dated 13.2.2014 by the Vipul Med Corp. TPA Pvt. Ltd.

     The exclusion clause 4.1 :-   Any pre-existing condition(s) as defined in the policy, until 48 months of continuous coverage of such insured person haves elapsed, since inception of his/her first policy with the Company.  Pre-Existing condition/Disease definition :- Any condition, ailment or injury or related condition (s) for which insured person had signs or symptoms, and/or received medical advice/treatment, within 48 months prior to his/her first policy with the Company.

     The OP has contested the complaint on merits has reiterated that the claim was not payable under the terms and conditions of the policy it has prayed for the dismissal of the complaint. 

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

          Copy of the order be made available to the parties as per rule.  File be consigned to record room.

          Announced in open sitting of the Forum on.....................

     (NIPUR CHANDNA)   (DR. VIKRAM DABAS)        (RAKESH KAPOOR)

                    MEMBER            MEMB ER                              PRESIDENT