ORDER
Complaint under Sec.12 of the CPA 1986 as amended upto date
Ms. Nipur Chandna, Member
Complainant is the mediclaim policy holder of the OP company vide policy No. 354100/48/11/8500003277 w.e.f. 13.2.2012 to 12.2.2013.
It is alleged by the complainant that she was admitted in Fortis Hospital, Shalimar Bagh, Delhi on 3.9.2012 and was discharged on 6.9.2012. It is further alleged by the complainant that the TPA of OP company denied the cashless facility to her and as such she made the payment of Rs.31,400/- to the hospital.
It is alleged by the complainant that she submitted all the relevant documents to the OP company for the reimbursement of her claim, but the OP company had repudiated her claim vide letter dated 16.5.2013 on false and frivolous ground.
The complainant, therefore, approached this Forum for the redressal of her grievance.
Complaint has been contested by the OP . OP company has filed its W.S. Para No. 13 ( b,c,d, and e ) of preliminary submission of W.S. filed by the OP is relevant and is reproduced as under: -
13. That the complainant has not placed true and correct facts before this Hon’ble Forum and has in fact tried to mislead this Hon’ble Forum by concealing the true and material fact. The true facts of the case are that:-
- The complainant was admitted from 03/09/2012 to 06/09/2012 (during the first year of policy) with diagnosis of Seronegative Poly Arthritis in Fortis Hospital, Shalimar Bagh Delhi.
- That after receipt of the claim from the complainant, the respondent company deputed Claim Department of M/s Safeway TPA Pvt. Limited to assess the claim of the complainant who submitted their report to the respondent company stating that the complainant had lodged a false claim. The said claim Department after discussing in detail gave their report. which is as under
"we have been officially appointed as a TPA to administer your medi claim policy of National Insurance Co. Ltd. we have been received the claim documents for the hospitalization of Pinki.
On going through the submitted documents for the hospitalization as mentioned above our medical team is of opinion that the claim does not falls under purview of the policy for the following reasons :-
18.9.2012
WAITING PERIOD FOR THE SPECIFIED DISEASE/AILMENTS/CONDITIONS (4.3) 2 YEARS
Hence we regret to convey that, the claim is not payable. We have retained the claim docket for future reference . "
- It is further stated that as per clause 4.1 Hospitalization Benefit Policy
EXCLUSION CLAUSE 4.1
All diseases/injuries which are pre existing when the cover incepts for the first time However, those diseases will be covered after Twenty four continuous claim free policy months. For the purpose of applying this condition, the period of cover under mediclaim policy taken from answering defendant only will be considered.
This exclusion will also apply to any complications arising from pre existing ailment/disease/injuries. Such complications will be considered as a part of the pre existing health condition or disease.
EXCLUSION CLAUSE 4.3
During the first one year of the operation of the policy of expenses on treatment of benign ENT disorders and surgeries like Tonsillectomy/adenoidectomy/Mastoidectomy/Tympanoplasty, treatment of disease such as Cataract, Benign Prostatic Hyperthropath, Hysterectomy, Hernia, Hydrocele, Congenital Internal disease, Fissures and fistula in anus, Piles Sinusitis and related disorders, Polycystic ovarian diseases, 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 Etc., if these disease/injuries are pre-existing at the time of proposal, will be covered only after four continuous claim free years.
Both the parties have filed their evidence by way of affidavits.
We have heard arguments advanced at bar and have perused the record.
The counsel for the OP has contended that the patient was admitted in Fortis hospital on 3.9.2012 and was discharged on 6.9.2012 with the diagnosis of seronegative poly arthritis and as the policy was first year policy, the claim of the complainant falls under Exclusion Clause No. 4.3 of the policy term and condition and has been rightly repudiated by the OP insurance company it had prayed for the dismissal of the complaint.
We are in agreement with the contention of the counsel for the OP .
The counsel for the OP has taken us through the discharge summary of the Fortis hospital, a copy of which has been placed on the record of this case. A bare perusal of the discharge summary makes it clear that the patient was diagnosed as a case of “seronegative Arthritis”.
We had also gone through the contents of exclusion clause no. 4.3 of the policy terms and condition which reads as under:-
EXCLUSION CLAUSE 4.3
During the first one year of the operation of the policy of expenses on treatment of benign ENT disorders and surgeries like Tonsillectomy/adenoidectomy/Mastoidectomy/Tympanoplasty, treatment of disease such as Cataract, Benign Prostatic Hyperthropath, Hysterectomy, Hernia, Hydrocele, Congenital Internal disease, Fissures and fistula in anus, Piles Sinusitis and related disorders, Polycystic ovarian diseases, 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 Etc., if these disease/injuries are pre-existing at the time of proposal, will be covered only after four continuous claim free years.
Admittedly, the complainant had taken treatment for the aforesaid disease during the first year of the inception of the policy purchased by her. Her case is therefore, covered under the aforesaid Exclusion clause.
We are of the opinion that the claim of the complainant which falls within the ambit of exclusion clause No. 4.3 of the policy was rightly repudiated by the OP .
In the light of above discussion we find no merits in the complaint. The same is hereby dismissed
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.....................
