Before the District Consumer Disputes Redressal Forum, Rohtak.
Complaint No. : 16.
Instituted on : 09.01.2018.
Decided on : 10.12.2019.
Smt. Jyoti age 35 years, wife of Satyender Kumar son of Sh. Dharampal resident of House no.1487/7, Goyat panna, Meham Distt. Rohtak.
………..Complainant.
Vs.
New India Assurance Company Limited, office at Jawahar Market, near Model Town, Rohtak-Delhi Road, Rohtak, through its Divisional Manager.
……….Opposite party.
COMPLAINT U/S 12 OF CONSUMER PROTECTION ACT,1986.
BEFORE: SH.NAGENDER SINGH KADIAN, PRESIDENT.
DR. RENU CHAUDHARY, MEMBER.
MS.TRIPTI PANNU, MEMBER.
Present: Sh.Ashwani Phougat, Advocate for the complainant.
Sh. A.S. Malik, Advocate for the opposite party.
ORDER
NAGENDER SINGH KADIAN, PRESIDENT:
1. Brief facts of the case are that the husband of complainant availed Mediclaim Insurance policy bearing no.353803341628-00000001 for the period 18.11.2016 to 17.11.2017 and the complainant being wife has Member ID no.9016567045. That during the period of alleged insurance, the complainant suffered from illness with a complaint ACCUTE LV and was treated at Maharaja Agrasen Hospital for the period 06.02.2017 to 11.02.2017 and incurred an amount of Rs.121574/- on treatment, medicines etc. That complainant intimated to respondent about the same and lodged the claim for the alleged amount along with required documents. That officials of the respondent acknowledged the same and treated the claim of the complainant. That despite repeated requests of the complainant, claim has not been settled by the opposite party which amounts to deficiency in service. Hence this complaint and it is prayed that opposite party may kindly be directed to pay the claim amount of Rs.121574/- alongwith interest, compensation and litigation expenses to the complainant as explained in relief clause.
2. After registration of complaint, notice was issued to the opposite party. Opposite party in its reply has submitted that complainant suffered from ASD, Severe PAH. As per documents provided it is noticed that the patient undergone Cath & Balloon occlusion study which revealed PVRI of wood units. ASD is an internal congenital disease and is payable in the third year of inspection of the policy. As per claim history of the patient, it is clear that the current policy is in second year of inspection. As this condition is not fulfilled. Therefore, the claim is not payable as per clause 4.4.6.2 ASD Severe PAH. So, claim is not payable under this policy of terms and conditions of policy. That the claim has been settled as per medi-claim scheme clause 4.4.6.2, in which patient suffered Acute LV was not covered as mentioned in letter dated 30.05.2017. So, the claim is not payable. All the other contents of the complaint were stated to be wrong and denied and opposite party prayed for dismissal of complaint.
3. Ld. counsel for the complainant in his evidence has tendered affidavit Ex.CW1/A, documents Ex.CW1 to Ex.CW9 and has closed his evidence on dated 31.10.2018. Ld. counsel for the opposite party has tendered affidavit Ex.RW1/A and documents Ex.R1 to Ex.R3 and closed his evidence on 01.03.2019.
4. We have heard learned counsel for the parties and have gone through material aspects of the case very carefully.
5. In the present complaint, as per the document Ex.CW8 the complainant was diagnosed for ASD with B/D Shunt as primary diagnosis. Meaning thereby the complainant has heart disease i.e. Acute LVF disease and the same is most common cause of heart failure. This disease results from build up of fatty deposit in the artery which reduces the blood flow and leads to heart attack. The cath and balloon occlusion study was done in the Maharaja Agrasen Hospital on 10.12.2017. As per the respondent, the patient was suffering from ASD, severe PAH as per the documents provided by him to the TPA of the respondent insurance company. The perusal of the documents shows that the patient undergo cath and ballooning occlusion study. Meaning thereby a minor surgery or ballooning was done by the doctors of Maharaha Agrasen Hospital. The contention of the respondent is that as per clause 4.4.6.2 of the terms and conditions of the policy, ASD with severe PAH i.e. congenital internal and external disease or defects or anomalies are not covered under the policy because these congenital internal diseases or defects or anomalies will not covered upto the 24 months of continuous coverage of the policy and thereafter the exclusion clause will remove. As per the respondent, this disease occurred in the 2nd year of the policy. Meaning thereby the 24 months had not completed by the policyholder. As per the claim history of the patient, it is clear that the current policy is in the second year of the inception.
6. In view of the facts and circumstances of the case, it is observed that the claim is not payable as per clause 4.4.6.2 of the terms and conditions of the policy. As such present complaint is hereby dismissed with no oder as to costs.
7. Copy of this order be supplied to both the parties free of costs. File be consigned to the record room after due compliance.
Announced in open court:
10.12.2019.
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Nagender Singh Kadian, President
……………………………….
Renu Chaudhary, Member.
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Tripti Pannu, Member.
