Paul Gomez, Member.
The case of the complainant is as follows:
Complainant is a family medi-claim policy holder of the opposite party. During the currency of the policy complainants wife was admitted in Lakeshore Hospital for treatment of her kidney failure. The complainant spent Rs. 3,52,266/- towards treatment expenses. The present complaint is to recover the said claim which had ben preferred before the opposite parties. Complainant contends that he is entitled for the said amount long with interest @ 12% p.a. from the date of claim till realization.
2. 1st opposite party filed the version, according to which the repudiation of claim was justified in law due to the fact that claim was preferred in respect of treatment of the disease that was pre-existing to the policy. Therefore opposite parties are of the view that they have valid ground for repudiation.
3. Complainant was not examined. However Exts. A1 & A2 were marked on his side. Witness for opposite party was examined as DW1. Opposite parties also produced Ext. B1 to B6 which were marked on their behalf. The learned counsel appearing for both sides were heard.
4. The points for consideration.
i. Whether repudiation of insurance claim is justified in law.
ii. What are the reliefs if any.
5. Complainant is the husband of the patient who was insured with the 1st opposite party under family mediclaim policy issued by them.
There is no dispute that the claim preferred by the insured for payment Rs. 3,52,266/- arose during the currency of the insurance policy with 1st opposite party. There is also no dispute that the said claim was raised to cover expenses incurred in respect of renal transplantation undergone by complainant’s wife. Unfortunately the said claim was dismissed by 1st opposite party on the ground of Ext. A4 advice tendered by their third party administrator. But the document indicating final rejection of the claim is not produced by either party. But from the pleadings of the 1st opposite party obviously the claim stands dismissed by them.
May be to show their rectitude in dealing with mediclaim, opposite party has produced Ext. B3 claim form to show that the amount claimed was disallowed because it was found that the treatment was given for the pre-existing disease of the kidney based on Ext. B2 discharge summary. To corroborate their up-right attitude. They contends that the claim to reimburse the expenses in respect of hysterectomy was not allowed in entirety only on account of her previous history of renal disease. The impugned claim, according to 1st opposite party was rejected on the ground of pre-existing disease by applying clause 41 of B6 policy.
According to Ext. A1 medical report of attending doctor, she was admitted for renal transplantation on 10-01-2007 and was discharged on 27-01-2007. It is pertinent to note that according to the report, the doctor was first consulted on 10-11-2006. It is more significant to take into account that the doctor has recorded that according to him the person could have been suffering from that illness since last 3 months. In that view of the matter how come the opposite parties dismiss the claim by taking shelter under the noting made by another doctor at an earlier occasion on Ext. B2 Discharge summary stating that the patient had been suffering from renal disease for the last 3 years since then. More importantly the said doctor has not mounted the box in the present proceedings. We do not think it is fair on the part of opposite parties to rely on the opinion of a doctor who had treated the patient earlier to dismiss claim pertaining to a subsequent episode of surgical procedure especially without examining. We think when conflicting opinion have been expressed by two doctors on the same subject, the opinion that has been made by the treating doctor in respect to which the present claim is lodged has an overriding credibility. Therefore we are of the view that by upholding the view of the doctor as expressed in Ext. A1 medical report rejection of claim as per Ext. B4 report can not be sustained. Consequently the dismissal of the claim for Rs. 3,52,266/- is not on valid grounds.
But it is significant to note that Exts. B5 and B6 would show that the maximum sum insured is only 2 lacs in an individual case. Therefore the complaint stands allowed subject to the aforesaid limitation.
Accordingly the complaint is partly allowed as follows:
1st opposite party shall pay to the complainant Rs. 2 lakhs (Rupees two lakhs only ) along with interest @ 9% p.a. from 02-02-2009, the date of complaint till realization.
The above said order shall be complied with within a period of one month from the date of receipt of a copy of this order.
Pronounced in the open Forum on this the 30th day of October 2010
