CONSUMER DISPUTES REDRESSAL FORUM – X
GOVERNMENT OF N.C.T. OF DELHI
Udyog Sadan, C – 22 & 23, Institutional Area
(Behind Qutub Hotel)
New Delhi – 110 016

Case No.271/2011

SH. AJAY DEVRANI
243B, REGENT SHIPRA SUN CITY
INDIRAPURAM,
GHAZIABAD-201014

                                 …………. Complainant                                                                                    

Vs.

M/S RELIANCE GENERAL INSURANCE COMPANY LIMITED,
60, OKHLA INDUSTRIAL AREA, PHASE-I,
NEW DELHI-110020

                                  …………..Respondents

                                            Date of Order:03.06.2015

O R D E R

A.S. Yadav - President

Complainant, Sh. Ajay Devrani was employed in FEV India (P) Ltd. at the relevant time.  He and his family members were covered under Corporate Mediclaim Policy with OP for the period 01.10.2008 to 3.9.2009.  Mrs. Bala Devrani w/o complainant was admitted in Apollo hospital, Sarita Vihar on 25.5.2009 for disc prolapse.  She was operated there and was discharged on 27.9.2009.  An expenditure of Rs.1,00,020/- was incurred on her treatment at Apollo Hospital.  Sum of Rs.5400/- was spent on MRI from Fortis Hospital before first surgery.  She was again admitted in Apollo Hospital on 08.9.2009 for disc prolapse and was operated and was discharged on 10.9.2009 incurring an expenditure of Rs.70,297/- at Apollo Hospital.  Sum of Rs.4875/- was spent on MRI at Kailash Hospital before second surgery.  Complainant asked OP for reimbursement of amount spent by him on treatment of his wife.  However the claim for Rs.100020/- was declined by OP vide letter dated 22.9.2009 on the ground that “it was found that the indoor papers show the duration of low backache as 2 years, whereas inception of the policy is 01.10.2008.  Therefore, this claim stands repudiated on the basis of policy exclusion 1 due to pre-existing disease, terms & condition 2 due to failure of disclosure of material facts and terms and condition 15 due to fraudulent claim”.  The claim in respect of Rs.70,297/- was also declined on the identical ground vide letter dated 03.2.2010.

The entire ground for repudiation of claim is based on the report of investigator who has referred to some Physiotherapy Assessment Form mentioning history of low back ache since last two years.  It is stated by complainant that there was no such Physiotherapy Assessment Form in which it is stated that low back ache was two years old.  The complainant stated in the rejoinder that if any such form is available, it may be shown to the complaint.  The complainant has specifically stated that in the discharge summary issued by Apollo Hospital it is mentioned that the disease was maximum 6 months old.

We have heard the complainant and have gone through the written submissions of the parties.  

It is not in dispute that w/o complainant was duly covered under the mediclaim policy which was valid for the period from 01.10.2008 to 30.9.2009.  The only ground for repudiation of claim is that she was having the back ache for the last two years as disclosed by her and recorded in the Physiotherapy Assessment Form and she had given wrong information that she was havin pain for the last three months.  In the discharge summary issued by Apollo Hospital, it is stated that the patient is having backache for the last 6 months however backache and radicular pain aggravated for the last three months meaning thereby on the day the policy was taken i.e. 01.10.2009, the patient was not having any pain so there was no question of concealment of any fact as alleged by the OP.  Complainant specifically stated in the rejoinder that there is no such form as Physiotherapy Assessment Form in which the patient has disclosed that she is having pain for the last two years and if there is any such form the complainant has requested OP to place the same on the record.  OP has not placed any such form on the record.  The onus was on the OP to prove on record the patient was having pre existing disease at the time of taking of policy and that fact was concealed by the patient.  In the discharge summary it is nowhere stated that the patient was having pain the last two years rather for the last 6 months which aggravated during the last three months.  There was no concealment on the part of assured.  It is a clear cut case of deficiency in service on the part of OP.

OP is directed to pay Rs.1,80,392/- to complainant alongwith interest @ 9% p.a. from the date from date of filing of complaint i.e. 23.6.2011.  OP is also directed to pay Rs.10,000/- towards compensation and Rs.5,000/- towards litigation expenses.

Let the order be complied within one month of the receipt thereof.  The complaint stands disposed of accordingly.

Copy of order be sent to the parties, free of cost, and thereafter file be consigned to record room.

           (EHTESHAM-UL-HAQ)                           (A.S. YADAV)
         MEMBER                                     PRESIDENT