ORDER Date: 08th August 2018
Ms. Rekha Rani President
The complainant is covered under group Insurance namely Family Manpower Solutions Pvt. Ltd., vide policy No. 3602000/46/14/8500000461. He was admitted in a Hospital on 08/09/2015 and was discharged on 11/09/2015. He was suffering from acute viral hepatitis and had incurred a sum of Rs. 28398/- on his treatment. The complainant lodged a claim with OP for refund of the aforesaid
amount. The claim was however repudiated by the OP on the ground that he was suffering from pre-existing disease. The complainant has alleged deficiency of service on the part of the OP and has made the following prayer :
In view of the above said submission, it is, therefore, most respectfully prayed to this Hon’ble Forum to direct the opposite party to pay a sum of Rs. 28,398/- towards bill amount and Rs. 5,00,000/- towards mental agony, torture, harassment, deficiency in service to the Complainant.
It is further prayed to this Hon’ble Forum to direct the opposite party to pay further Rs. 25,000/- as legal expenses to the complainant.
Any other and further relief(s), which this Hon’ble Forum may deem fit and proper in the given facts and circumstance, may also be passed in favour of the complainant and against the opposite party.
The OP has contested the complaint and had filed a reply. It has however admitted that the complainant was covered under the standard group mediclaim policy issued by it for the period from 22/12/2014 to 21/12/2015. It has admitted that the complainant had remained admitted in Max Hospital from 08/09/2015 to 11/09/2015. It has however stated that his claim was rightly repudiated under the terms and conditions of the policy clause 4.1 which is reproduced as under :
‘’All pre-existing diseases when the cover incepts for the first time until 48 months of continuous coverage has elapsed. Any complication arising from pre-existing ailment/
/disease/injuries will be considered as a part of the pre existing health condition or disease.
To illustrate if a person is suffering from either hypertension or diabetes or both at the time of taking the policy, then policy shall be subject to following exclusions.’’
Diabetes | Hypertension | Diabetes and Hypertension |
Diabetic Retinopathy | Coronary Artery Disease | Diabetic Retinopathy |
Diabetic Nephropathy | Cerebro Vascular Accident | Diabetic Nephropathy |
Diabetic Foot/Wound | Hypertensive Nephropathy | Diabetic Foot/wound |
Diabetic Angiopathy | Internal Bleeding/ Haemorrhage | Diabetic Angiopathy |
Diabetic Neuropathy | | Diabetic Neuropathy |
Hyper/Hypoglycemic shock | | Hyper/ Hypoglycemic shock |
Coronary Artery Disease | | Coronay Artery Disease |
| | Cerebro Vascular Accident |
| | Hypertensive Nephropathy |
| | Internal Bleeding / Haemorrhage |
It has claimed that the complainant had suppressed material facts and there was absence of bonafides on his part. It has claimed that the complainant was diagnosed as a case of Gilbert Syndrome in the past but the complainant did not supply the past medical record despite request from the OP. It has claimed that the complainant was having a history of Gilbert Syndrome and Jaundice and was thus suffering from a pre-existing disease which he had failed to disclose at the time of purchase of the policy. It has therefore prayed that the complaint be dismissed.
On behalf of the complainant an affidavit was filed dated 3/01/2017 in support of the complaint. OP has filed an affidavit of Sh. Ajay Sethi Senior Divisional Manager dated 25/01/2017.
We have heard Sh. Manoj Kumar learned counsel for complainant and Sh. P.K. Dwivedi learned counsel for the OP and have perused the record.
The sole question for consideration is as to whether the OP was justified in repudiating the claim lodged by the complainant. Exhibit CW 1/7 is the discharge summary prepared at Max Hospital in respect of the treatment given to the complainant. It records that the complainant had suffered from an acute viral hepatitis. He had a history of suffering from Jaundice 1 year back. Exhibit CW 1/5 is a certificate issued by Dr. Deepak Lahoti, the treating Dr. at Max Hospital which reads as under :
‘’Certified that Mr. Devender Kumar (IP No. 215718) was admitted under my care on 08/09/2015. We made a
diagnosis of acute viral Hepatitis. His illness was not
related to any other problem like Gilberts Syndrome. He
has shown good recovery from his illness.’’
Sd/-
DR. DEEPAK LAHOTI
MD. DM
SENIIOR GASTROENTROLOGIST
MAX SUPERSPECIALITY HOSPITAL
PATPARGANJ DELHI
DMC 10227, MOBILE 9810123067
A perusal of the aforesaid two documents makes it amply clear that the treatment of the patient for viral hepatitis had no relation to any earlier diagnosis that the patient was suffering from Gilbert Syndrome. Gilbert Syndrome is a genetic disorder in which liver does not properly process bilirubin and is due to a mutation in the UGT1A1 gene which results in decreased activity of the bilirubin uridine
diphosphate glucuronosyltransferase enzyme and has no co-relation with acute viral hepatitis which is caused by hepatitis viruses (A,B,C,D,E) .
We are therefore of the considered opinion that the repudiation of the claim of the complainant by the OP was unwarranted and illegal.We hold that OP was
guilty of deficiency of service and direct it as under :
- Pay to the complainant a sum of Rs. 28398/- along with interest @ 10% per annum from the date of filing of this complaint till realization.
- Pay to the complainant a sum of Rs. 25,000/- for pain and agony suffered by the complainant.
- Pay to complainant a sum of Rs. 10,000/- as litigation cost.
This order shall be complied with by the OP within a period of 30 days from the date of receipt of this order failing which interest @ 10% shall be payable on the entire above mentioned amount till realization. Copy of this order be sent to the parties as per rules. File be consigned to record room.
Announced on this 8th day of August 2018.
