Delhi

New Delhi

CC/338/2009

P.K. Gupta - Complainant(s)

Versus

M/S. Iffco Tokio General Insurance Company Ltd. - Opp.Party(s)

25 Aug 2015

ORDER

CONSUMER DISPUTES REDRESSAL FORUM-VI

(DISTT. NEW DELHI), ‘M’ BLOCK, 1^STFLOOR,

VIKAS BHAWAN, I.P.ESTATE,

NEW DELHI-110002.

 

Case No.CC/338/09                       Dated:

In the matter of:

SH. P K GUPTA

S/O SH.LATE SH. B D GUPTA,

R/O L1/217 A, DDA FLATS,

KALKAJI, NEW DELHI

THROUGH AUTHORIZED REPRESENTATIVE,

PUNEET GUPTA.

 

                   ……..COMPLAINANT

 

VERSUS

 

1.THE MANAGER

IFFKO TOKIO GENERAL INSURANCE CO. LTD.

OFFICE AT: 505, 5^TH FLOOR,

KAILASH BLDG.

6, KASTURBA GANDHI MARG,

CONNAUGHT PLACE,

NEW DELHI-110001

 

2. THE MANAGER

IFFKO TOKIO GENERAL INSURANCE CO. LTD.

IFFCO HOUSE, 3^RD FLOOR,

34, NEHRU PLACE,

NEW DELHI-110019.

 

3.PARAMOUNT HEALTH SERVICES PVT. LTD.

F-90/12, NEAR ESI HOSPITAL,

OKHLA INDUSTRIAL AREA,

PHASE-1, DELHI-110020

 

………. OPPOSITE PARTY

 

ORDER

President: C K CHATURVEDI 

 

The short facts of alleged deficiency are that complainant took a Individual Medi Shield Policy 16.3.2006 from OP. 

The policy was renewed in subsequent years.  The complainant suffered heart attack in Jhansi and was admitted to Escort Heart Institute, Delhi from 4.1.2008 to 10.1.2008 and received a bill for Rs.58,618/- (annexed with complaint).  A claim was filed and was repudiated.  Thereafter complainant was hospitalized again from 30.1.2008 to 6.2.2008 and paid a bill for a sum of Rs.83,875/-.   A claim was filed.  The complainant again was hospitalized from 24^th May, 2008 to 9^th June, 2008 and paid a bill for a sum of Rs.2,74,754/-.  All claims were rejected on grounds of patient having diabetes for 8 years. 

OP in its WS has stated that claim was repudiated under pre-existing clause wherein the medical documents shows that patient was known case of triple vessel coronary artery diseases with diabetes (8 years) and since the ailment is existing before the inception of policy, the claim was repudiated.

We have gone through rival pleading in consonance with their sworn affidavit.  It is well settled law that malaise of hypertension, diabetes, headache etc. are normal wear and tear of modern day life controllable by standard medication and cannot be termed as disease unless the insured has concealed hospitalization for the said disease. 

Hon’ble State Commission in Appeal No 931/05 in the case of NIC Co. Ltd. Vs. Shri Chand Jain has elucidated the same under Para 11,12 & 16 and the same is reproduced as below:

11.     Thus malaises of diabetes, hypertension, occasional anginal pain in the body or organs, fever at times, ischemia, anginal pain are not such diseases non-disclosure of which ma be used for repudiating the claim against medi-claim policy.  These are normal wear and tear of human life.  Unless a person is hospitalized for the treatment or operated upon, he cannot be held to be suffering from a ‘pre-existing’ as he undertakes day-today activities and attends to daily chores and duties.

12.     Why does a person obtain medi-claim policy?  He obtains it to meet the medical expenses incurred by him for hospitalization or operation for specific disease.  Fact that insured cannot be reimbursed the daily expenses incurred by him for medicines being taken by him regularly or on day-to-day basis shown that claim against such a policy is permissible only if an insured is hospitalized or operated upon for curing the specific disease.  Thus non-disclosure of above-referred maladies is insignificant.  These are not such diseases that fall within the ‘exclusion clause’ for the purpose of medi-claim policy.

16.      Non-disclosures of a factum of having been hospitalized or operated upon for the treatment or cure of a specific disease in the near proximity say six months or a year prior to taking the policy may be used for repudiating the claim for the reason of non-disclosure of pre-existing disease as in that even, element of malafied of the insured cannot be ruled out.

 OP has not filed an iota of evidence disclosing previous hospitalization due to diabetes.

We, therefore, fixed OP  guilty of deficiency in service and direct OP to pay Rs.1,42,493/-(Rs.58,618/- plus Rs.83,875/-) under policy No.,52019428 which was valid from 16.3.01-15.3.08 and to pays Rs.2,74,754 under Policy No.52077664 which was valid from16.3.08 to 15.3.09 both with 9% interest from date of  claim till realization.  We also award Rs.50,000/- as compensation for harassment, mental trauma inclusive of  litigation expenses.

The order shall be complied with within 30 days of the receipt of the copy of the order; otherwise action can be taken under Section 25 / 27 of the Consumer Protection Act.

Copy of the order be sent to the parties free

of cost.

Pronounced in open Court on 25.08.2015.

 

 

(C.K.CHATURVEDI)

PRESIDENT

 

 

 (RITU GARODIA)

MEMBER