ORDER
V. K. DABAS, MEMBER
In brief, the case of the complainant is that he was taking mediclaim individual policy along with his wife for the last 19 years from the OP company. The proposal form was filled only at the time of taking the first policy and no proposal forms were asked to be filled by the OP at the time of renewal of each policy. It is alleged by the complainant that in the year 2010 the OP company increased the coverage amount of mediclaim policy to Rs. 6,00,000/- on his request but the name of the policy was changed from mediclaim policy to Happy Family Floater Policy without his consent and also the Family Floater Policy could not have been issued in his name as per rules(proposer above 55 years of age are not eligible to take this consent). It is alleged by the complainant that he developed dry cough which was not cured by local treatment , hence he got himself admitted in the hospital where he was found to be suffering from Ostium Secundum defect with left to right shunt after not conducting a number of tests on him. It is further alleged by the complainant that the claim filed by him for the expenditure incurred on treatment amounting to Rs 2,51,798/- was repudiated by the OP. The complainant filed appeal before the grievance cell of the OP insurance company who also repudiated his claim on the ground that the disease is internal congenital and the same is not covered by the policy. The complainant has , therefore, approached this forum for redressal of his grievance.
The OP has contested the complaint and has filed its written statement. It is submitted by the OP that it is not liable to pay any amount to the complainant as there is no deficiency of service on its part. It has stated that the complainant was a known case of Atrial Septal Defect and was admitted on 29.8.2011 for ASD Closure. It is further submitted by the OP that the ailment of the complainant is congenital in nature and as per terms and conditions of the insurance policy i.e. Happy Family Floater Policy congenital (internal and external both) disorders are excluded under clause no. 4.8 of the policy. Hence, the claim was rightly repudiated as per the terms and conditions of the policy.
The complainant has filed his evidence by way of affidavit and has corroborated the contents of the complaint. The complainant has put on record copies of insurance policies from 2008 to 2011, copy of repudiation letter ,copy of the claim filed and copy of discharge summary. The OP has also filed its evidence by way of affidavit and has reiterated the contents of the written statement.
We have heard arguments advanced at the bar and have perused the record.
Firstly, the question for our consideration is whether the OP was justified in changing the mediclaim policy (individual ) of the complainant to Happy Family Floter Policy. It is the case of the complainant that neither he was intimated nor his consent was taken by the OP prior to converting the policy from mediclaim poliy (individual )to Happy Family Floter Policy. A perusal of the record shows that the OP has failed to place any document on record scoring that the consent of the complainant was obtained before changing the policy. The OP has failed to put on record any proposal form filled by the complainant opting for Happy Family Floter Policy. Rather it has filed an affidavit of Sh. Suresh gupta Deputy Manager that the proposal form is not available with it. It can , therefore be safely assumed that the consent of the complainant was not taken while change in policy. It has also to be noticed that the OP has issued the Happy Family Floter Policy to the complainant at the age of 60 years and has failed to put on record any medical examination certificate by a competent doctor which is in violation of clause AGE of the Happy Family Floter Policy. The relevant portion of the clause AGE of the happy family floter policy is reproduced as under:-
Clause AGE
The age of the proposer is taken as the entry age. The proposer plus at least one member of the family has to be necessarily an insured under the policy. The entry age of the proposer is from 21 to 55 years and no medical examination is to be insisted for the entry. Proposers above 55 years of age are not eligible to take the policy . Such Family members who are above 60 years of age will be included only on production of the medical examination from a qualified medical practionter not below the rank of MD. The current guidelines under individual mediclaim policies will be applicable for the family policy also.
The change in policy was thus in violation of the guidelines issued on this behalf. We are, therefore, inclined to hold that the complainant continued to be covered by the terms and conditions of the individual mediclaim policy.
Secondly, the question for our consideration now is as to whether the OP was justified in repudiating the claim lodged by the complainant. OP has contended that the claim was not payable as per exclusion clause 4.8 of the terms and conditions of policy of insurance purchased by the complainant. The OP has relied upon the terms and conditions of the happy family floater policy. This was not the policy purchased by the complainant. He had purchased an individual mediclaim policy. Reliance on Exclusion Clause 4.8 of the happy family floater policy was therefore misconceived and cannot be made the basis of the repudiation of the claim. Exclusion clause 4.8 of the mediclaim policy (individual) is relevant for arriving at a decision in this complaint and is reproduced as under:-
Convalescence, general debility, run-down condition or rest cure, congenital external disease or defects or anomalies, sterility, venereal disease, intentional self injury/suicide all psychiatric and psychosomatic disorders and diseases / accident due to and or use abuse of drugs/ alcohol or use of intoxication substances or such abuse or addiction etc.
The OP has repudiated the claim on the ground that a case of ASD (Ostium Secundum ) with left to right shunt is an internal congenital defect. It is clearly stated in the exclusion clause 4.8 cited above that only external congenital defects are excluded under this clause. From the above discussion we are of the considered opinion that in the facts and circumstance of the case repudiation of the claim was unjustified and un-called for. We hold OP guilty of deficiency in service and direct it as under:-
- Pay to the complainant the claim a sum of Rs 2,51,798/- along with interest at the rate of 10% p.a. from the date of filing of this complaint i.e. 21-2-2013 till payment.
- Pay to the complainant a sum of Rs. 2,500/- as compensation for pain and agony suffered by him.
- Pay to the complainant a sum of Rs. 5000/- as cost of litigation.
The above amount shall be paid by the OP to the complainant within 30 days from the date of this order failing which OP shall be liable to pay interest on the entire awarded amount @ 10% per annum from the date of this order till the date of payment. If OP fail to comply with the order within 30 days, the complainant may approach this Forum u/s 27 of the Consumer Protection Act.
Copy of this order be made available to the parties free of cost as per law and Case File be consigned to Record Room.
Announced in open sitting of the Forum on.....................
