DISTRICT CONSUMER DISPUTES REDRESSAL FORUM
(CENTRAL) ISBT KASHMERE GATE DELHI
CC No. 435/2016
No. DF/ Central/ Date
Shri Ajay Kumar Mishra
S/o Sh. Surya Kant Mishra
R/o T-663/A, Gali No. 21,
Baljeet Nagar, Patel Nagar,
New Delhi - 110008
.....COMPLAINANT
VERSUS
1. M/s. Alankit Insurance TPA Ltd.
Having its office at:-
Alankit House, 4E/2,
Jhandewalan Extension, New Delhi – 110055
2. M/s. National Insurance Company Ltd.,
Having its Divisional Office At:-
VIII, C-30, Pooja House,
1st Floor, Karampura, New Delhi - 110015
3. Sh. Shamshad Alam Khan ( Code No. 4747)
Agent of National Insurance Company Ltd.,
At:- VIII, C-3, Pooja House,
1st Floor, Karampura,
New Delhi - 110015
…..OPPOSITE PARTY
Ms. Rekha Rani President
Sh. Vikram Kumar Dabas, Member Mrs. Manju Bala Sharma, Member
ORDER Date: . .2018
Sh. Vikram Kumar Dabas
1. The complainant had purchased a policy of Mediclaim Insurance form OP 1 for an assured sum of Rs. 3 Lacs. It was effective for the period from 27/08/2015 to 26/08/2015. On 24/04/2016 the complainant was admitted in Sir Ganga Hospital where he was diagnosed as a case of Tuberculoma in Mid brain. He was discharged from the Hospital on 30/04/2016 and had incurred a sum of Rs. 1,33,011 as the expenses on his treatment. He had lodged a claim with the OPs who failed to pay the same. Hence the complaint. The complainant has made the following prayers :
- Direct the Opposite Party No. 1 and 2 make the payment of the claimed amount of Rs. 1,33,011/- (Rs. One Lac Thirty Three Thousand Eleven Only), along with interest at the rate of 18% per annum from the date of lodging of the claim till the date of its actual payment.
- Grant compensation to the complainant on account of mental pain and agony caused to the complainant due to undue harassment meted out to the complainant by the O.P.
- Grant cost of present proceedings and litigation expenses incurred by the complainant.
- Grant any other and further relief as this Hon’bel forum may deem fit and proper in the facts and circumstance of the case.
2. The complainant has been contested by the OPs. A reply has been filed on behalf of OP 1, wherein the following dispute has been taken under the head preliminary submission.
‘’ That the respondent ‘’National Insurance Co. Ltd.’’ had granted to the complainant a Mediclaim Insurance Policy bearing number 360300/48/15/85000002751. The Insurance was granted subject to terms & conditions as stated in the policy. The respondent is enclosing a copy of these Terms & Condition no. 4.3 of the policy read as under:-
Exclusion Clause 4.3 During the first two years of the operation of insurance cover, the expenses on the treatment of diseases such as Cataract, Benign Prostatic Hypertrophy, Hysterectomy, Hernia Hydrocoele, Internal Congenital Defects/ Diseases of Anomalies, Fistula in Anus, Piles, Chronic Fissure in Anus, Pilonidal Sinus, Sinusitis, Stone disease of any site, Benign Lumps / growths in any part of the body CSOM (Chronic Suppurative Otitis Media) Joint replacement of any kind unless arising out of accident, Surgical treatment of Tonsils & Andenoids, Deviated Nasal Septum and related disorder are not payable. If these diseases (other than congenital internal disease/defect) are pre-existing at the time of proposal, they will be covered only after four continuous claim free years as mentioned in exclusion 4.1 above.
If the insured is aware of the existence of congenital internal disease/defect before inception of the policy, the same will be treated as pre-existing.
The complainant lodged a claim with the respondent for reimbursement of the expenses incurred on alleged treatment of himself at Satyabhama / Gangaram Hospital on 16.4.2016 & from 24.4.2016 to 30.4.2016. On scrutiny of the Claim documents it was found that the patient was admitted for tuberculoma in mid brain caused due to previous infection & was also suffering from diabetes & hypertension. Hence the claim is not payable & merits repudiation.’’
3. OP 1 has contested the complaint on merits and has prayed for its dismissal. The complainant has filed his own affidavit wherein he has reiterated the contents of the complaint filed by him. OP has also filed an affidavit of evidence and has corroborated the contents of the written statement.
4. We have heard arguments advanced at the bar and have perused the record. Our attention has been drawn to the discharge summary prepared at Sir Ganga Ram Hospital which shows that the complainant was diagnosed as a case of Tuberculoma in mid brain. Under the head clinical history the following is recorded :
‘’A 41 – year old male patient with no known co-morbidities presented with complaints of giddiness, which was acute in onset since morning, associated with nausea and visual blurring. Visual blurring was transient and lasted for an hour and recovered spontaneously. Patient had multiple similar episodes in past 1 month. There was no history of head trauma, loss of consciousness, seizure, headache, omitting, fever, tinnitus. MRI Brain was done which was suggestive of mid brain ring (?NCC). Now patient is admitted in SGRH for further evaluation and management.’’
Under the head clinical summary the following is recorded:
‘’Patient was admitted with above mentioned complainants. He was started an conservative management. MRS was done which revealed the possibility of a tuberculoma in the midbrain. Chest medicine reference was sought and CECT Chest and Abdomen was done which revealed evidence of enlarged necrotic mediastinal lymph nodes with clustered nodulo-parenchymal infiltrates in left upper lobe, which may represent changes due to pulmonary Koch’s. Irregularity with reduced size of the left kidney with significant irregularity of the upper polar region of the left kidney. Patient was stared on ATT. FNAC and sputm evaluation was done which was positive. Gradually patient improved. Now he is being discharged in stable condition with further advice to follow up.’’
5. The sole question for our consideration is whether the insurance company was justified in repudiating the claim under exclusion clause 4.3 as stated / reproduced in para 1 of the written statement under the head preliminary submissions. On a consideration of the treatment record and the discharge summary we are of the considered opinion that the case of the complainant was not covered under the exclusion clause 4.3 and his claim was unjustifiably repudiated. The complainant had suffered from tuberculoma of the midbrain
which is a space occupying lesion (SOL) cannot be termed as a benign lump or
growth. Tuberculoma of midbrain is an infectious disease caused by Mycobacterium Tuberculosis and is not a benign lump of growth. Tuberculoma of midbrain is life threatening disease. Our attention has been drawn to page no. 41 of the complaint which depicts that the bills amounting to Rs. 1,33,011/- for total expenses incurred by the complainant on his treatment have been submitted to the OP and the same are not opposed by the OP. In para 10 of complaint it is submitted that claim for Rs. 1,33,011/- was submitted which is not denied in corresponding para 10 of the reply. In view of the above discussion we allow the complaint and direct OP 1 as under :
1. Pay to the complainant a sum of Rs. 1,33,011 - (One Lac Thirty Three and Eleven Rupees only) along with interest at the rate of 10% from the date of institution of the complaint i.e. 02/01/2017 till the date of realization.
2. Pay to the complainant a sum of Rs. 20,000/- (Twenty Thousand only) as compensation for pain and agony suffered by him.
3. Pay to the complainant a sum of Rs. 5,000/- (Five Thousand only) as cost of litigation.
6. 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 ______ day of _______ 2018.
