DISTRICT CONSUMER DISPUTES REDRESSAL FORUM
(CENTRAL) ISBT KASHMERE GATE DELHI
CC No. 407/2016
No. DF/ Central/ Date
Mrs. Beena Lal, R/o House No. 252, Ghitorni Enclave Pahari,
Mehrauli Gurgaon Road, New Delhi
.....COMPLAINANT
VERSUS
1. M/s. Oriental Insurance Co. Ltd.,
88, Janpath, Ground Floor, New Delhi
Also at :
A-25/27, Asaf Ali Road,
New Delhi …. OPPOSITE PARTY NO. 1
2. M/s. Medi Assist India TPA Pvt. Ltd.,
B 20, Sector – 2, Noida - 201301
…..OPPOSITE PARTY NO. 2
Ms. Rekha Rani President
Sh. Vikram Kumar Dabas, Member Mrs. Manju Bala Sharma, Member
ORDER Date: . .2018
Sh. Vikram Kumar Dabas
The complainant had purchased a policy of Medical Insurance from OP 1 which was effective for the period from 18/03/2013 to 17/03/2014. On 10/01/2014 the complainant was admitted to Artemis Hospital Gurgaon for her treatment and was discharged on 13/01/2014. Cashless facility was denied to her and the claim lodged by her for reimbursement of the amount spent by her on her treatment was also repudiated. The complainant has alleged deficiency in service on the part of the OPs and has prayed as under :
- Direct the opposite party No. 1 & 2 to refund/pay the bill amount i.e.
Rs. 48,599.33/- to the complainant with interest from the date of payment made by the complainant to the hospital.
- Direct the opposite party No. 1 & 2 to pay a sum of Rs. 5,00,000/- to the complainant towards the mental pain, agony, financial loss etc. suffered by the complainant due to non-action and deficiency of service on the part of the Respondents.
- Direct the Opposite Parties to pay a sum of Rs. 44,000/- towards litigation charges to the complainant.
- Any other order to relief which this Hon’ble Court may deem fit and proper may also be passed in favour of the complainant and against the opposite party No. 1 & 2.
The complaint was contested by OP 1 who has filed a written statement and has claimed that the complaint is misconceived and is an abuse of the process of law. It has claimed that the claim was rightly repudiated as the Insured was suffering from a pre-existing disease at the time of purchase of the policy and had suppressed the said fact. It has also claimed that the claim was not payable under clause 4.2 of the policy terms and conditions which provided that the expenses on treatment on some diseases which are contracted/manifested during the currency of the policy are not payable for a period 2 years. It has prayed for the dismissal of the complaint.
In the evidence the complainant has filed its affidavit reiterating the
contents of the complaint. The OP has also filed an affidavit of evidence corroborating the contents of the written statement.
We have heard arguments at the bar and have perused the record. Our attention has been drawn to the policy T & C and in particular to clause 4.2 which reads as under:
‘’The expenses on treatment of following ailment/diseases/surgeries for the specified periods are not payable if contracted and /or manifested during the currency of the policy. If these diseases are pre-existing at the time of proposal the exclusion no. 4.1 for pre-existing conditions SHALL be applicable in such cases.
(XVII) | Hypertension | 2 Years |
A perusal of the aforesaid clause as extracted above makes it amply clear that expenses incurred on the treatment of Hypertension or related disease is not reimbursable. In the present case the policy was purchased by the complainant on 18/03/2013 and she was treated for the ailment of accelerated Hypertension on 10/01/2014 i.e. within 02 years of the inception of the policy. The claim was therefore, not payable under the aforesaid clause of the policy. We therefore, hold that the claim was rightly repudiated by the insurance company. We see no merits in this case, the same is hereby dismissed. Copy of the order be supplied to the parties as per rules. Announced on this 12th day of April 2018.
