1.
DISTRICT CONSUMER DISPUTES REDRESSAL FORUM (CENTRAL)
MAHARANA PARTAP BUS TERMINAL: 5th FLOOR.
KASHMERE GATE DELHI.
No. DF / Central/ 2015
Consumer Complaint No | : | CC 92/2010 |
Date of Institution | : | |
| | | |
Satender Jain,
R/o B-26,
Preet Vihar,
New Delhi ..........Complainant
Versus
- The Divisional Manager,
National Insurance Company Ltd
Division XIV, 13/32, W.E.A.,
Arya Samaj Road, Karol Bagh, New Delhi
- National Insurance Company Ltd
3, Middleton Street,
Post Box No. 9229,
The third party Administrator (T.P.A.)
National Insurance Company Ltd
Alankit House 2E/21,
Jhandewalan Extension,
New Delhi-110005
..........Respondent/OP
BEFORE
SH. RAKESH KAPOOR, PRESIDENT
DR. VIKRAM KR. DABAS , MEMBER
Nupur Chandna , MEMBER
ORDER
Per Sh. RakeshKapoor, President
The complainant had taken a Pariwar Mediclaim Policy from OP1 on 6.10.2008. ON 12.11.2008 , he had suffered from a chest pain and was
2.
taken to Sunder Lal Jain Hospital where he underwent an Angioplasty and was discharged on 15.11.2008. He had lodged a claim with the OPs for the expenses incurred on the above treatment which was repudiated on the ground that the claim was not payable under clause 4.1 of the terms and conditions of the policy. The complainant has alleged that this action of the OP was unjustified and unwarranted . Hence, the complaint.
OP1 has contested the complaint and has filed a written statement. Paras 3 and 4 of the preliminary objections reads as under:
3.That it is submitted that the complainant had cooked up a false and frivolous story of illness and admission on 12/11/2008. It is further submitted that the complainant has been residing at B-26, Preet Vihar Delhi-110092. It is strange to note that the patient taken to M/s Sunder Lal Jain Hospital, Ashok Vihar, New Delhi which is situated 15-20 K.M. from his house for treatment in a small hospital where as many large and reputed hospital are nearby to his residence. If there arise any urgency to admit in a nursing home then complainant should be admitted in vicinity of his house as there’re many famous hospital and nursing home are there in the nearby area. Further intimation of admission was not immediately given to Opposite Party as per the term and conditions of the policy and thereby violate clause 5.3 of the policy which provide that :
“Upon the happening of any event, which may give rise to a claim under the policy , notice with full particulars shall be sent to the company within 7 days from the death, injury, hospitalization.”
And complainant had allegedly intimated on 20/11/2008, hence, the complaint deserves to be dismissed on this ground alone.
- That the claim of the complainant is not maintainable as the claim of the complainant
-
pertaining to disease CAD: Acute Coronary Syndrome Significant Single Vessel Disease. Low Normal LV Systolic Function (LVEfs 0.55). Grade 1 Diastolic Dysfunction. PTCA+DES to RCA with Tirofiban infusion. are inadmissible as the above disease was pre-existing since the policy is only one month 6 days old.
It is further submitted that OP / Company on the above grounds repudiate the claim of complainant by letter dated : 25/05/2009 its liability in accordance with clause no. 4.1 of the pariwar Mediclaim which reads as :
Clause 4.0 provided that “ The company shall not be liable to make any payment under the policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of :
Clause 4.1 read as “All Disease/ injuries which are pre existing when the cover incepts for the first time. However, those disease will be covered after found continuous claim free policy years. For the purpose of applying this condition, the period of cover under mediclaim policy taken from National Insurance Company only will be considered.
“ Pre existing disease like Diabetes and Hypertension will be covered from the inception of the policy on payment of additional premium by the insured. “Hence the complaint deserves to be dismissed on this ground alone.”
4.
The OP has contested the complaint on merits and has reiterated that the claim had been rightly rejected and was not payable.
We have heard arguments advanced at the bar and have perused the record.
On behalf of the OP an affidavit has been filed by Sh. Rajiv Shatdhal a Senior Divisional Manager. He has reiterated the defence taken in the written statement by OP1 and has claimed that the claim was rightly repudiated as the deceased was suffering from a pre-existing disease. He has referred to clause 4.1 of the policy purchased by the complainant. He has placed on record a copy of the Pariwar Mediclaim Policy. Apart from this the OP has placed no document on record to show that the complainant was suffering from a coronary artery disease prior to the purchase of the policy. The OP has assumed that since the complainant had undergone an Angioplasty he would have suffered from a Coronary Heart Disease prior to purchase of the policy. It is common knowledge that these days people are unaware of the ailments like Coronary Heart Disease unless they are subjected to some tests to evaluate their problem. In the present case, there is no evidence that any previous tests were undergone by the complainant which had shown that the complainant had suffered from a heart disease. It may be that it was for the first time that the complainant had been admitted to the hospital and had learnt about the disease. In the absence of any medical record showing that the complainant had suffered from the aforesaid disease earlier to the purchase of the policy of insurance, the OP insurance company was not justified in repudiating the claim.
We, therefore, hold that the OP1 insurance Company deficient in rendering services to the complainant and direct it as under:-
- Pay to the complainant a sum of Rs. 2,75,800/-.
- Pay to the complainant a sum of Rs. 30,000/- as compensation for pain and agony suffered by it.
-
3.Pay to the complainant a sum of Rs. 5,000/ as cost of litigation .
The OP1 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 OP1 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.....................
(NUPUR CHANDNA) (DR.V.K.DABAS) (RAKESH KAPOOR)
MEMBER MEMBER PRESIDENT
