ORDER
Complaint under Sec.12 of the CPA 1986 as amended upto date
Ms. Nipur Chandna, Member
Complainant got insured himself and his family members with the OP no. 1 vide policy no. 360300/48/12/8500003554 w.e.f. 7.11.2012 – 6.11.2013 for a sum of Rs.3,00,000/-
It is alleged by the complainant that on the morning of 6.4.2013 he started feeling slowness of speech, headache, left sided weakness and as such he was admitted on the same day in I.C.U. with OP no. 2, and was discharged on 10.3.2014.
It is alleged by the complainant that after discharge from the hospital he lodged a claim with OP 3 alongwith original bills vide claim no. NI-3-156629.
It is further alleged by the complainant that the OP had issued him letter dated 14.5.2013 thereby asked him to submit the certificate of treating doctor in respect of the previous history of his ailment, and he had duly submitted the same to the OP accordingly.
It is alleged by the complainant that even after receiving the certificate by the treating doctor OP had repudiated his claim on false and flimsy ground vide letter dated 9.7.2013 with the reason that:-
“It has been observed that as per MRI – disc bulge with significant cord compression without
any history of accident or recent traumatic injury. Medically it takes long time for significant disc bulge, means Pre-existing disease.
Hence the said claim falls under clause 4.1 of the policy.
The complainant therefore approached this Forum for the redressal of his grievance.
Complainant has been contested by OP No. 1 & 3. OPs have filed their written statement, they have denied any deficiency on their part. Para No. 3 of the preliminary objection of W.S. filed by OP no. 1 & 3 is the relevant and same is reproduced as under:
3.The complainant lodged a claim with the respondent for reimbursement of expenses incurred by him for treatment in Fortis Hospital at Shalimar Bagh during the period 6.4.2013 to 10.4.2013 & submitted medical papers . On perusal of these papers it was observed as per MRI brain a copy of which is annexure R-2 that this was a case of disc bulge at C-3, C-4 level causing the cal sac indentation and significant cord compression with thinning of cord and foci of increased signal intensity on T2W images suggestive of cord edema/myelomalacia. Medically speaking disc bulge with significant cord compression without any history of accident or recent traumatic injury takes long time. Since there was no history of accident or recent traumatic injury. Hence, it was observed that the complainant was suffering from this disease since long before effecting insurance. This disease comes under the category of pre existing disease and the claim lodged by the complainant was not payable as per provisions contained in clause no 4 and 4.1 of the insurance policy as referred to hereinabove.
We have heard arguments advanced at bar and have perused the record.
The counsel for the OPs has contended that on perusal of MRI Brain report it was found that the patient was suffering from speaking disc Bulge with significant Cord Compression without any history of accident or recent traumatic injury. He has contended that the complainant was suffering from such an ailment since long before effecting insurance and as such the present ailment falls under the category of pre-existing disease. He has contended that the claim lodged by the complainant was rightly repudiated by the OP as per the provision contained in clause nos. 4 and 4.1 of the insurance policy.
Counsel for the complainant on the other hand had stated that on 6.4.2013 for the first time complainant started feeling slowness of speech, headache, left side weakness and due to this reason he got himself admitted in ICU on the same day. He has contended that hence the disease of the complainant is not pre-existing disease and the case of the complainant does not fall under the ambit of clause 4 and 4.1 of the Insurance policy.
It is further contended by the counsel for the complainant that the OP had repudiated the claim of the complainant on false and flimsy grounds without considering the certificate issued by treating doctor Sh. Rajat Agarwal who had certified that the complainant had no history of hypertension and diabetics.
We have considered the rival contentions. Having gone through the documents placed on record, we are of the considered opinion that the case of the complainant does not fall within the ambit of pre-existing disease which is proved by the certificate issued by Dr. Rajat Aggarwal, the treating doctor. A perusal of MRI brain report shows that the complainant was suffering from disc bulge at C-3, C-4 level with significant Cord compression. The OP company vide letter dated 14.5.2013 had demanded from the complainant the certificate of treating doctor mentioning therein the duration of any past history of HTN or Not, which was provided by the complainant to the OP . But the OP company had repudiated the claim of the complainant without considering the certificate issued by treating doctor, on an assumption that the complainant was suffering from the present ailment since long before the purchase of the insurance policy.
OP Nos. 1 and 3 had failed to place on record any material suggesting that the present ailment was prevalent prior to the inception of the policy. OPs have not filed any medical literature to support their conclusion which is based on assumptions and conjectures ought not to have repudiated the claim of the complainant. We therefore hold OP -1 guilty of deficiency in services and direct it as under:-
- Pay to the complainant a sum of Rs.85,586/- (Rupees Eighty Five Thousand & Five Hundred Eighty Six Only) @ 10% p.a. from the date of filing of the complaint i.e. 27.8.2013 till payment.
- Pay to the complainant a sum of Rs.10,000/- (Ten Thousand only) for mental agony and pain suffered by him.
- Pay to the complainant a sum of Rs.5000/-(Rupees Five Thousand only) as a cost of litigation.
The OP shall pay this amount within a period of 30 days from the date of this order failing which they shall be liable to pay interest on the entire awarded amount @ 10% per annum. If the OP fails to comply with this order, the complainant may approach this Forum for execution of the order under Section 25/27 of the Consumer Protection Act.
Copy of the order be made available to the parties as per rule. File be consigned to record room.
Announced in open sitting of the Forum on.....................
