PER SHRI. S.S. PATIL – HON’BLE MEMBER
1) This is the Complainant regarding deficiency in service on the part of Opposite Party as they repudiated the legitimate insurance claim of the Complainant.
2) The facts of this case as stated by the Complainant are that the Opposite Party had issued Hospitalisation and Domiciliary Hospitalisation Benefit Policy in favour of Mrs.Veena Shivdasani and the Complainant vide Policy No.111200048062070003243 valid from 29/06/06 to 28/06/2007 covering the Complainant and his wife for the sum of Rs.50,000/- each. During the validity of this policy, in the month of May, 2007, the Complainant was not feeling well and he had loose motions. Hence, he approached Dr.M.B. Agarwal. Dr.Agarwal conducted several tests on the Complainant. It was averred by the Complainant that, apart from other things it was found that the Complainant had tested positive for HIV1. On 23/06/2007, the Complainant had breathing problem and weakness. Hence, he was admitted in Bombay Hospital Trust and Medical Research Centre on 24/06/2007. (In para 5 of the complaint the Complainant has typed this date as 24/06/2008. It appears that it is typographical mistake). At this time he was treated in Bombay Hospital for Bronchitis and on 28/06/07 he was discharged.
3) After discharge, the Complainant lodged his insurance claim with Opposite Party No.2 through Opposite Party No.1 for an amount of Rs.90,000/- (Here the Complainant has not mentioned the date on which he lodged his insurance claim with Opposite Parties) all the medical papers and bill in original, were submitted to the Opposite Parties.
4) The Complainant received a letter dtd.19/07/07 from the Opposite Party No.1 that the claim lodged by the Complainant stands non payable under exclusion clause 4.9 of the policy. Clause 4.9 is “All expenses arising out of any condition directly or indirectly caused to or associated with Human TCell Lymphotropic virus type III (HTL III) or Lymohadinopathy Associated virus (LAV) or the Mutants Derivative or Variation Deficiency Syndrome or any Syndrome or condition of a similar kind commonly referred to as AIDS are not payable. The Complainant was admitted for complaints of generalized weakness and shortness of breath. As per investigation reports & other document, the Complainant was diagnosed case of Human Immune Deficiency virus infection. As expenses related to this ailment is not covered under the policy etc. On receipt of this letter the Complainant sent several representations to the Opposite Party No.2 expressing that his claim is payable as he was not treated for HIV1 but for Bronchitis, but invain.
5) The Complainant has averred that the Opposite Parties have repudiated his genuine claim which amounts to deficiency and unfair trade practice on the part of the Opposite Party. Hence, the Complainant has prayed that the medical expenses of Rs.90,000/-be reimbursed by the Opposite Party with interest and a compensation of Rs.50,000/- for mental agony and harassment caused to the Complainant in addition to the cost of this complaint, to be paid to the Complainant.
6) The Complainant has attached the relevant medical insurance policy alongwith terms and conditions, the discharge certificate from Bombay Hospital, other relevant medical papers and medical bills in respect of the hospitalisation of the Complainant from 24/06/07 to 28/06/07.
7) The complaint was admitted and notices were served on the Opposite Parties. Opposite Party No.2 appeared through its Ld.Advocate. Opposite Party No.1 did not appear before this Forum inspite of the service of notice on it. Therefore, no written statement order was passed vide roznama dtd.08/10/08. Opposite Party No.2 filed its written statement wherein Opposite Party No.1 has justified the repudiation of the insurance claim of the Complainant on the ground of exclusion clause 4.9 of the insurance policy as mentioned in para 3 above. The Opposite Party No.2 further averred that there is no deficiency in service on its part. The Opposite Party No.2 has added that the Complainant had also approached the Ombudsman vide complaint No.GI706 of 200-2008. In this complaint also the Ombudsman passed the award stating that the claim of the Complainant is not tenable under the policy.
8) The Opposite Party has also pointed out that the sum insured for the Complainant is only Rs.50,000/- but the Complainant has raised the claim of Rs.90,000/- which is not correct.
9) Finally the Opposite Party No.2 has prayed that the claim of the Complainant is not payable as per the terms and conditions of the insurance policy and as such, the complaint be dismissed with cost.
10) The Complainant thereafter filed rejoinder-cum-affidavit of evidence wherein the fact mentioned in the complaint are reiterated. The Ld.Advocate for Opposite Party No.2 vide letter dtd.16/02/09 had prayed that the written statement be treated as written argument and oral argument.
11) We heard the Ld.Advocate for the Complainant and perused all the papers submitted by both the parties and our findings are as follows –
During the validity of the mediclaim insurance policy, the insured Complainant was hospitalized in Bombay Hospital Trust and Medical Research Centre from 26/06/07 to 28/06/07 for generalized weakness and shortness of breath. These ailments were persisting since 2½ months before his admission. We carefully scrutinized the medical papers submitted by the Complainant and it is seen that there was a chest problem, e coli infection present in the Complainant. But the discharge certificate does not mention any final diagnosis. However, the history & examination /findings column shows - “Pt is known case of DM (diabetics : 9 years. Pt is known case of HIV (Herpes 1 year. Pt has come with c/c/o Generalized weakness & shortness of breath since 2½ months.”
From the medical papers as well as the Complainant’s averment in the complaint it is seen that the Complainant is known case of HIV infection. The treatment was given to the Complainant for the above all ailments taking into consideration that he is an H.I.V. patient. Therefore, expenses for such a treatment are excluded under clause 4.9 of the policy as it stipulates that all expenses arising out of any condition directly or indirectly caused to or associated with Human TCell Lymphotropic Virus III (ITL III) or Lymohadinopathy Associated Virus (LAV) or Mutanta derivatives or variation Deficiency Syndrome or any Syndrome or condition of a similar kind commonly related to as AIDS are not payable. Therefore, in our considered opinion, the case of the Complainant comes under the purview clause 4.9 of the insurance policy and hence, the mediclaim of the Complainant is not payable. Thus the Opposite Parties have rightly repudiated the same. Hence, there is no deficiency in service or unfair trade practice adopted by the Opposite Party as it was repudiated after considering the terms and conditions of the policy. Hence, we pass the following order -
O R D E R
i)Complaint No.132/2008 is hereby dismissed with no order as to cost.
ii)Copy of this order be furnished to both the parties.
