CONSUMER DISPUTES REDRESSAL FORUM – X
GOVERNMENT OF N.C.T. OF DELHI
Udyog Sadan, C – 22 & 23, Institutional Area
(Behind Qutub Hotel)
New Delhi – 110 016
Case No.168/2012
SH. SAJID AHMED
S/O SH. SIRAJ AHMED
R/O RZ-2061-A, GALI NO.27,
TUGHLAKABAD EXTENSION,
NEW DELHI-110019
…………. COMPLAINANT
Vs.
- M/S EAST WEST ASSIST PVT. LTD.,
97, MANEKSHAW ROAD, SAINIK FARMS,
NEW DELHI-110062
- M/S NATIONAL INSURANCE COMPANY LTD,
12, COMMUNITY CENTRE, 3RD FLOOR,
EAST OF KAILASH, NEW DELHI-110065
…………..RESPONDENTS
Date of Order:09.08.2016
O R D E R
A.S. Yadav – President
The case of the complainant is that he obtained a mediclaim insurance policy from OP-2 for the period 25.11.09 to 24.11.10. It was a cashless policy and the cashless hospitalisation card was issued by OP-1. The complainant was admitted in Batra Hospital on 15.04.2010 for some hip problem and was discharged on 20.04.10. At the time of admission, the complainant gave the cashless card to the authorities who sent the estimate to OP for approval but OP declined the facility of the cashless claim on the ground that documents given by them are not satisfactory and asked them to submit all original documents/report alongwith the claim form at the time of reimbursement of the claim.
It is further stated that the complainant was having pain in his hip for the last few months and was taking medicines form local doctor. The complainant only came to know about the disease when he approached the doctors of Batra Hospital. The OP simply denied the cashless facility by saying that the age related osteoarthritis and osteoporosis are not payable for the first four years of the operation of the policy.
It is further stated that the complainant incurred an expenditure of Rs.2,29,862/- on his treatment and OP refused to reimburse the aforesaid amount without any reason. It is a clear cut case of deficiency in service on the part of OP. It is prayed that the OP be directed to pay the medical claim of Rs.2,29,862/- alongwith 18% interest p.a. and also pay a sum of Rs.50,000/- as compensation.
OP in the reply took the plea that the insurance policy was valid for the period 25.11.09 to 24.11.10 and the complainant has confirmed over the phone before taking the policy that he was not having any medicalim policy prior to this. The claim was repudiated in view of Exclusion Clause 4.3 which reads as under:-
“Exclusion Clause 4.3 - During the first one year of the operation of the policy the expenses on treatment of benign ENT disorders and surgeries like Tonsillectomy/adenoidectomy/Mastoidectomy/ Tympanoplasty, treatment of disease such as Cataract, Benign Prostatic Hyperthropathy, Hysterectomy, Hernia, Hydrocele, Congenial Internal disease, Fissures and Fistula in anus, Piles Sinusitis and related disorders. Polycystic ovarian disease, Non infective arthritis, undiscended testis, surgery of gall bladder and bile duct excluding malignancy, surgery of Genito-urinary system excluding malignancy, Pilonidal Sinus, Gout and rheumatism, Hypertension, Diabetes, Calculus Disease, Osteoarthritis and Osteoporosis etc., if these disease/injuries are pre-existing at the time of proposal, will be covered only after four continuous claim free years.”
It is stated that in the present case the claimant is covered under policy since 25.11.2009 and as mentioned in claim form. Patient did not have any past policy. The claim merits repudiation as per exclusion clause 4.2 and 4.3 of the Mediclaim Policy. Therefore the respondent was eminently justified in repudiating the claim of the plaintiff.
The only point of repudiation of the claim is on account of the pre-existing disease. Complainant in the rejoinder disputed the fact that he was not having any policy prior to this. It is stated that in fact complainant was insured by the OP vide policy No.35170/48/08/8500001797 for the period 25.11.2008 to midnight of 24.11.2009. Subsequently the said policy was renewed vide policy No.35170/48/09/8500001947 for the period 25.11.2009 to midnight of 24.11.2010. The said policy was renewed vide policy No.35170/48/10/8500002142 for the period 25.11.2010 to midnight of 24.11.2011.
We have heard Ld. Counsel for the parties and carefully perused the record.
The only point of repudiation of claim is that since the complainant was suffering from pre-existing disease hence in terms of clause 4.3 of the policy, the complainant was not entitled for treatment of the disease in question for the first four years of the operation of the policy. This was stated on the basis of hospitalisation claim form for reimbursement submitted by the complainant with OP-1 wherein it was stated that the disease was detected on 04.11.2009. The discharge summary of the Batra hospital shows that complainant was taking medicine from the local doctor. It is not that the complainant was ever admitted in any hospital for the treatment of this disease. The complainant has stated that he was having a pain in his bilateral hip. Simply because a person having a pain in his hip means that he was aware that it was because of severe osteoarthritis of right hip. Reference in this regard is placed on the judgment of Hon’ble Delhi State Consumer Dispute Redressal Commission, New Delhi in case of The Oriental Insurance Company Vs Mr. Vidya Sagar Vohra & Ors. Appeal No.FA-08/98 decided on 13.03.2008. In that case the kneecap had to be replaced because of the injury suffered by the complainant. The claim was repudiated on the ground of concealment of pre existing ailment of osteoarthritis. The plea was taken that necessity for replacement of kneecap could not arise suddenly in six months unless disease of osteoarthritis was pre existing since long time. The claim was allowed by the District Forum and the appeal was dismissed by the Hon’ble State Commission. In para 7 and 9, the Hon’ble State Commission held as under:-
“7.We have taken a view that unless and until a person is hospitalized for treatment of any disease or undergone any operation in the near proximity of taking the policy, say a year or two before, he cannot be accused of concealing the factum of any disease, which can be termed as pre-existing disease.
9. Every beneficial policy or contract of insurance has to be interpreted and given a beneficial meaning. Contracts of insurance are always for the benefit of the insured and any other approach, which is not a consonance with the beneficial interpretation or ingredient, is bad in law.”
There was no justification in repudiating the claim. OP by way of its reply tried to bring an impression that the policy was taken on 25.11.09 and the complainant was already suffering from this disease and was knowing about it even on 04.11.09. In fact it is not so. Complainant has already taken a policy from OP on 25.11.08 to 24.11.09 and the policy was renewed on 25.11.09 to 24.11.09 and was again renewed form 25.11.10 to 24.11.11. So it is not that it is within first year of the taking of the policy the disease was detected. When the policy was taken the complainant was not suffering from any disease. Repudiation was totally unjustified.
OP-2 is directed to refund pay a sum of Rs.2,21,491 /- to complainant alongwith interest @ 9% p.a. from the date of filing of the complaint. OP is also directed to pay Rs.15,000/- towards compensation and Rs.5,000/- towards litigation expenses.
Let the order be complied within one month of the receipt thereof. The complaint stands disposed of accordingly.
Copy of order be sent to the parties, free of cost, and thereafter file be consigned to record room.
(D.R. TAMTA) (RITU GARODIA) (A.S. YADAV)
MEMBER MEMBER PRESIDENT
