DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II
Udyog Sadan, C-22 & 23, Qutub Institutional Area
(Behind Qutub Hotel), New Delhi- 110016
Case No.306/2010
Sh. Vipin Bhatia
S/o Sh. Dayanand Bhatia
R/o H.No.244-A2, Shivaji
Pandit Park, Delhi-110051 ….Complainant
Versus
The Senior Manager
Reliance General Insurance,
Policy Servicing Branch Office
3rd Floor, Presidency Tower,
351/2, Mehrauli Gurgaon Raod
Beside Kalyani Hospital Delhi
M/s Reliance General Insurance Company,
Reliance Centre, 19 Watch & Heena Chand Marg,
Bilard Estate,
Mumbai - 400001 ….Opposite Party
Date of Institution : 07.05.2010
Date of Order : 24.12.2021
Coram:
Ms. Monika A Srivastava, President
Sh. U.K. Tyagi, Member
ORDER
President: Ms. Monika A Srivastava
The Complainant through the present complaint has prayed for a sum of Rs.1,60,000/- with interest and other legal expenses on account of deficiency in service on the part of OP-1 and OP-2. The present complaint has been filed against Reliance General Insurance Company i.e. OP-2 and OP-1 being the Senior Manager of OP-2.
It is the case of the Complainant that a Mediclaim Policy was issued to him but at the time of issuance of said policy, no medical checkup was done. It is further stated that the Complainant had requested the OP that he may be checked medically before granting of the Mediclaim Policy however the representative of the OP ignored his request and stated that as he is below 50 years of age, no medical checkup is required. Further, the Complainant was assured that OP will takeover the policy provided by National Insurance Company (hereinafter to be referred as NIC) to the Complainant and all the benefits given by NIC would be continued by the present company. On these terms, the Mediclaim policy was issued to the Complainant for the period 31.07.2007 to 01.08.2008 and another policy in continuation to 01.08.2008 to 31.07.2009 for a sum of Rs.2,00,000/-.
The Complainant further states that he was not suffering from any pre-existing disease. It has also been stated in the Policy “Gold Plan Column No.5 & 7” that the pre-existing disease expenses would be covered from the third year of the policy after two continuous renewals of this policy with the company. Sometime later, the Complainant was diagnosed by a disease “MARFAN’S SYNDROME, ASSCENDING AORTIC ANEURYSM, MOD AR NSr, Ieo, CCFo”. He was admitted on 25.03.2009(as per annexure ‘P-36’) and discharged from AIIMS on 05.04.2009(as per annexure ‘P-38’) and he spent an amount of Rs.1,60,000/- on his treatment (as per annexure ‘P-41’). The complainant claims that his claim was rejected (the letter is annexed at Exhibit-OPW-1/B) on the ground that the Complainant was suffering from pre-existing disease.
OP-1 and OP-2 have refuted the allegations of the Complainant and have stated that the complaint is liable to be dismissed as per the Health Wise Policy Terms and Conditions Clause No.10 that the claimant was hospitalized for the treatment of Marfan’s Syndrome which the OP claims to be a genetic disorder and took the surgical management for the same. As per the policy’s terms and conditions, treatment related to this ailment is not payable; therefore, Complainant’s claim was rightly repudiated by the OP No.2 vide repudiation letter dated 02.12.2009. The clause 10 is reproduced as under:
“treatment of obesity, general debility, convalescence, run down condition or rest cure, congenital external/internal disease, illness or defects or anomalies, sterility, venereal disease or intentional self injury and use of intoxicating drugs alcohol”
Evidence as well as written submissions of both the parties are on record. The complainant has not led any evidence to show that the disease for which he was operated upon could have been a result of any other cause other than Marfan’s syndrome. The discharge summary by AIIMS is clear in this regard.
In a recent judgment in Jai Prakash Tayal vs United India Insurance in RFA No. 610/2016, the Hon’ble Delhi High Court has held….
(ii) Discrimination in health insurance against individuals based on their genetic disposition or genetic heritage, in the absence of appropriate genetic testing and laying down of intelligible differentia, is Unconstitutional;
(iii) The broad exclusion of genetic disorders' is thus not merely a contractual issue between the insurance company and the insured but spills into the broader canvas of Right to Health. There appears to be an urgent need to frame a proper framework to prevent against genetic discrimination as also to protect collection, preservation and confidentiality of genetic data. Insurance companies are free to structure their contracts based on reasonable and intelligible factors which should not be arbitrary and in any case cannot be 'exclusionary. Such contracts have to be based on empirical testing and data and cannot be simply on the basis of subjective or vague factors. It is for lawmakers to take the necessary steps in this regard.
(iv) The Exclusionary clause of genetic disorders', in the insurance policy, is too broad, ambiguous and discriminatory hence violative of Art.14 of the Constitution of India;
However, this judgment has been stayed by the Hon’ble Supreme Court by its order dated 27.08.2018.
In the absence of any evidence and any supporting judgment, we are unable to grant any relief to the complaint. The complainant is bound by the terms and conditions of the insurance policy issued to him and we find no deficiency in service on the part of the OP in repudiating the claim. The complaint is dismissed with no order as to costs.
File be consigned to the record room after giving copy of the order to the parties. Order be uploaded on the website.
