ORDER
PER SH. RAKESH KAPOOR, PRESIDENT

The complainant had purchased a mediclaim policy from the OP   which
was valid for the period 30.5.2013 to  25.5.2014.  It is alleged by
the complainant that Smt Murti Devi Saini  (one of the beneficiaries
under the policy) was admitted for treatment for palpitation in St.
Stephens Hospital Delhi on 3.6.2013 and was discharged on 4.6.2013.
He had incurred a sum of Rs. 18,300/- on her treatment and had claimed
its  refund from the OP . The claim was , however, repudiated on the
plea that the insured was suffering from a pre-existing disease. The
complainant has alleged that the repudiation of the claim was
unwaranted and was  uncalled for.  Hence, the complaint.
The Op has contested the complaint and has filed a written statement.
It has denied any deficiency in service on its part and has claimed
9that the complaint is liable to be dismissed.   It has prayed
accordingly.   Para 8 of the preliminary objections is relevant in
this regard  and is reproduced as under:
8. That the true facts of the case are that the complainant and her
husband were issued a Mediclaim Policy bearing policy No.
351200/48/13/8500000239 for the period 30.05.2013 to 29.05.20 14 for a
sum of Rs. 5.00 Lacs and the liability of the company, if any, is
subject to terms and conditions of the policy. A pre-authorization
letter was received from the complainant through St. Stephen Hospital
for authorization of Rs. 18,300/- by M/s Raksha TPA Pvt. Ltd. a third
party administrator on behalf of the respondent. In the said pre
authorization form it is shown that the patient Srrit. Maurti Devi was
suffering from hypertension from the last 8 years. The said form was
duly signed by the doctor as well as patient Smt. Murti Devi as the
policy was not an old policy. Therefore, the said pre-authorization
was declined by the M/s Raksha TPA Pvt. Ltd. Thereafter, a claim along
with bill of St. Stephen Hospital amounting to Rs. 8171/- only was
received from the complainant. On going through the documents the
complainant’ has obtained the opinion of Dr. Sharad Mathur, who
submitted his report dated 22.07.2013. After going through the said
report the eompanv has repudiated the claim herein, non-admissible as
per Clause No. 4. 1 of policy terms and conditions as pre-existing
disease.
The exclusion clause No. 4. 1 of policy terms and conditions is as under:“
all diseases/injuries which are pre-existing when the
cover incepts for the first time. However, those diseases will be
covered after four continuous claim free policy years, for the purpose
of applying this condition, the period of cover under Mediclaim policy
taken from National Insurance Co. only will be considered.”
Since the policy is in 3i1 year, therefore, the said disease does not
cover under the said policy. Accordingly, the claim was repudiated and
the complainant was informed vide letter dated 28.10.2013. Therefore,
the present complaint of the complainant is not maintainable and is
liable to be dismissed with heavy costs.


The OP has contested the complaint on merits and has reiterated that
the complaint has no merits and is liable to be dismissed. It has
prayed accordingly.
We have heard arguments advanced at the bar and have perused the record.
The sole question for determination before us is as to whether the
claim lodged by the complainant has been rightly repudiated by the
insurance company or not.   The insurance company has repudiated the
claim on the basis of a pre-authorization  form  which was submitted
with the TPA for release of cashless facility to the complainant.
In the pre-authorization form, it was recorded that the insured was
suffering from hypertension for a period of 8 years.   Apart from this
there is no document on record, showing that the insured was suffering
from hypertension for such a long period.   The discharge summary
prepared at St. Stephens Hospital shows that the insured/ patient  was
a known case of hypertension for a period of ¾ months only.  The
complainant  had also made available to the OP a certificate from the
treating doctor  which reads as under:-
Certificate”
This is to certify that the above mentioned patient , a case of
palpitation under evaluation and hyperthyroidism was recently
diagnosed with hypertension 3-4 months back.
Sd/-
Dr. Amit Taneja.  St Stephens hospital.


It appears to usthat the insurance company has simply ignored the
aforesaid certificate and has not considered the same while
repudiating the claim lodged by the complainant.
In our considered opinion, therefore, the insurance company was not
justified in repudiating the claim lodged by the complainant.  In this
context we may note a judgment of Delhi State Commission reported as
IV ( 2008) CPJ 511 Oriental Insurance Company Ltd V/s Mahinder Singh
(Dr). In the said  case , the State Commission, Delhi had an occasion
to deal with the meaning and the concept of the word “disease” as well
as the “pre-existing disease”.  The commission had observed as under:-
6.A person comes to know about the medical terminology of a particular
disease when he lands in the hospital and undergoes treatment or
operation. If a person had suffered heart attack or got treatment for
a particular disease say 10-15 years before and has been leading
healthy and normal life he is not supposed to disclose the factum of
having undergone treatment or operation for particular disease 10-20
years before. It is only the disease which is existing at the time of
obtaining the policy or in the near proximity of it for which the
insured has undergone any treatment or operation which is pre-existing
disease and not the disease for which the man had already obtained the
treatment and cured himself and was leading healthy life of a healthy
person.
The commission had further observed:-
7.Our conclusions on the meaning and import of words disease,
pre-existing disease for the purpose of mediclaim insurance policy,
are as under:
(i)Disease means a serious derangement of health or chronic
deep-seated disease frequently one that is ultimately fatal for which
an insured must have been hospitalized or operated upon in the near
proximity of obtaining the mediclaim policy.
(ii)Such a disease should not only be existing at the time of taking
the policy but also should have existed in the near proximity. If the
insured had been hospitalized or operated upon for the said disease in
the near past, say, six months or a year he is supposed to disclose
the said fact to rule out the failure of his claim on the ground of
concealment of information as to pre-existing disease.
(iii)Malaise of hypertension, diabetes, occasional pain, cold,
headache, arthritis and the like in the body are normal wear and tear
of modern day life which is full of tension at the place of work, in
and out of the house and are controllable on day to day basis by
standard medication and cannot be used as concealment of pre-existing
disease for repudiation of the insurance claim unless an insured in
the near proximity of taking of the policy is hospitalized or operated
upon for the treatment of these diseases or any other disease.
(iv)If insured had been even otherwise living normal and healthy life
and attending to his duties and daily chores like any other person and
is not declared as a diseased person as referred above he cannot be
held guilty for concealment of any disease, the medical terminology of
which is even not known to an educated person unless he is
hospitalized and operated upon for a particular disease in the near
proximity of date of insurance policy say few days or months.
(v)Disease that can be easily detected by subjecting the insured to
basic tests like blood test, ECG etc. the insured is not supposed to
disclose such disease because of otherwise leading a normal and
healthy life and cannot be branded as diseased person.
(vi)Insurance Company cannot take advantage of its act of omission and
commission as it is under obligation to ensure before issuing
medi-claim policy whether a person is fit to be insured or not. It
appears that insurance Companies dont discharge this obligation as
half of the population is suffering from such malaises and they would
be left with no or very little business.
Thus any attempt on the part of the insurer to repudiate the claim for
such non-disclosure is not permissible, nor is exclusion clause
invokable.
(vii)Claim of any insured should not be and cannot be repudiated by
taking a clue or remote reference to any so-called disease from the
discharge summary of the insured by invoking the exclusion clause or
non-disclosure of pre-existing disease unless the insured had
concealed his hospitalization or operation for the said disease
undertaken in the reasonable near proximity as referred above.
(viii)Day to day history or history of several years of some or the
other physical problem one may face occasionally without having landed
for hospitalization or operation for the disease cannot be used for
repudiating the claim. For instance an insured had suffered from a
particular disease for which he was hospitalised or operated upon 5,
10 to 20 years ago and since then had been living healthy and normal
life cannot be accused of concealment of pre-existing disease while
taking mediclaim policy as after being cured of the disease, he does
not suffer from any disease much less the pre-existing disease.
(ix)For instance, to say that insured has concealed the fact that he
was having pain in the chest off and on for years but has never been
diagnosed or operated upon for heart disease but suddenly lands up in
the hospital for the said purpose and therefore is disentitled for
claim bares dubious design of the insurer to defeat the rightful claim
of the insured on flimsy ground. Instances are not rare where people
suffer a massive attack without having even been hospitalised or
operated upon at any age say for 20 years or so.
(x)Non-disclosure of hospitalization/or operation for disease that too
in the reasonable proximity of the date of mediclaim policy is the
only ground on which insured claim can be repudiated and on no other
ground.
8. Had the deceased been suffering from such disease he would not have
continued to live ordinary life by performing all the chores and
ordeals and that too after being subjected to basic medical test by
the panel doctors of the insurance company. On the aforesaid criteria
and particularly taking clue from the discharge summary of the patient
is no ground for rejection of the claim. The onus is on the insurance
company to prove that the insured concealed the factum that he has
been suffering from the pre-existing disease at the time of obtaining
the policy.

From the discussion above , we hold that the OP insurance company was
deficient in rendering services to the complainant. We  , therefore,
direct the OP insurance company as under:

1. Pay to the complainant a sum of Rs. 18,300/-  along with interest @
10% p.a. from the date of institution of this complaint i.e. 31.1.2014
till payment
2.Pay to the complainant a sum of Rs. 7,500/- as compensation for pain
and agony suffered by hm.
3.Pay to the complainant a sum of Rs. 2,500/- as 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 fail 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.....................