The complainants have filed the present complaint against the O.P u/sec. 12 of Consumer Protection Act, 1986. The facts as alleged in the complaint are that the complainant had taken individual mediclaim policy No.215400/48/2010/157 on 16.4.2009 for Rs.2, 35,000/-. This policy was renewal of old policy dated 24.4.2008. It is alleged that above policy dated 16.4.2009 states “the insurance under this policy is subject to conditions, clauses, warranties”. The complainant alleged vomited blood from his mouth on 24.7.2009 and immediately reported to AIIMS Hospital. After checkup, the complainant was diagnosed for RHD, severe MS MILD to MODERATE TRH etc. and admitted in hospital on 26.11.2009, operated on 27.11.2009 and discharged on 4.12.2009. It is alleged that mediclaim/bill of Rs.1,03,195 was submitted to the OP on 24.2.2010 but they kept mum inspite of repeated reminders and personal visits and lastly an RTI petition was filed on 8.12.2010 for reimbursement of above mediclaim. It is alleged that in reply to RTI, the complainant received a letter on 10.1.2011 from the O.P in which it was stated that “the claim has been rejected under clause NO.4.3 and 4.1 but the copy of the policy bond and contents of clause No.4.3 and 4.1 were never supplied to the complainant. It is alleged that policy was issued without any condition. It is alleged that the complainant has made various requests and reminders to the O.P for reimbursement of the claim of complainant but all in vain. On these facts complainants pray that O.P be directed to pay Rs.1,03,195/- + Rs. 50,000/- apart from cost and compensation as claimed.
2. O.P appeared and filed written statement. In its written statement, OP has not disputed that complainant had taken individual mediclaim policy on 16.4.2009 for Rs.2,35,000/-. The case of the O.P is that the illness of the complainant diagnosed is inadmissible under clause 4.3 and 4.1 of the terms and conditions of Individual Mediclaim Policy. This illness is not covered during first 2 years of insurance as it takes long time to develop hence makes this disease as pre-existing. It is alleged that complainant has concealed the true facts from the OP and did not disclose about the disease at the time of taking the policy. It is alleged that the O.P had rejected the claim of the complainant. As per records the mediclaim policy was taken for the first time for the period 25.4.2008 to 24.4.2009 and thereafter the policy was renewed from 25.4.2009 to 24.4.2010, therefore, the disease of the complainant diagnosed covers under clause 4.3 and 4.1 of the terms and conditions of Individual Mediclaim policy and is not covered during first 2 years of insurance as it takes long time for the diagnose to develop hence make this disease as pre-existing illness from the scope of the policy, therefore, the claim becomes inadmissible. It is alleged that as per terms and conditions pre-existing disease is not covered in the above said policy. Dismissal of the complaint has been prayed for.
3. Complainant has filed his affidavit affirming the facts alleged in the complaint. On the other hand Shri Ram Sukh, Divisional Manager has filed affidavit in evidence on behalf of O.P testifying all the facts as stated in the written statement. Parties have also filed their respective written submissions.
4. We have carefully gone through the record of the case and have heard submission of Ld. Counsel for the complainant.
5. From the perusal of the record we do not find that there is any dispute that the complainant had taken mediclaim policy from 25.4.2008 to 24.4.2009 which was renewed for the period from 25.4.2009 to 24.4.2010. It is also not disputed that the complainant fell ill on 24.7.2009 and was admitted on 26.11.2009 in AIIMS Hospital and spent a sum of Rs.1,03,195/-. According to the complainant terms and conditions relied upon by the OP were not supplied to him. OP stated that terms and conditions of the policy were supplied to the complainant and he accepted the same. It is also the case of OP that case of the complainant feeling under exception under clause 4.3 and 4.1 of the terms and conditions attached with the policy.
6. We have pursued the policy issued to the complainant, at the end of the policy it has been mentioned there is a clause which proved “the insurance under this policy is subject to conditions, clauses, warranties, endorsements as per forms attached “against the column, OP has mentioned “NIL” . It is therefore, clear that no documents like terms and conditions were supplied to the complainant. Case of the OP is that complainant accepted by clause 3.4 and 3.5 as mentioned in OPW-1-1. When the terms and conditions of policy were not attached with policy OP cannot be allowed to rely upon the document which was never part of the policy. If we pursued the policy for the period 25.4.2008 to 24.4.2009, in both the policies terms and conditions were not supplied. Therefore, terms and conditions which were not the part of policy. Therefore in our opinion repudiation of claim were not justified.
7. Case of the complainant is also that complainant concealed true facts of this claim and did not mention the same at the time of taking the policy. OP has not placed on record proposal form so that we could have benefit of going through the same and come to the conclusion that the complainant had concealed the facts. Even otherwise no evidence has been placed by the OP on record, which shows the complainant was suffering from RHD, severe MS MILD to MODERATE TRH at the time of taking the policy. Therefore, we cannot say that repudiation of the claim of complainant is justified.
8. In these circumstances the only order which can be passed at this stage is, we direct the O.P to reconsider the claim of the complainant in the light of observations made in this order. Accordingly, we direct the O.P to reconsider the claim of the complainant and decide it one way or the other within a period of 30 days. Ordered accordingly. The order shall be complied within 30 days of receipt of this order.
Copy of the order be sent to the parties by Registered post and the file be consigned to record room.
Announced this 08th day of December,2014.
