As per Shri Atul Alsi, Hon'ble President.

1. The complainant has filed present complaint u/s. 12 of Consumer Protection Act, against the arbitrarily repudiated of medical claim and thereby claiming reimbursement of medical claim under the policy of  Rs.467994/- alongwith compensation of  Rs.1,00,000/- and for damages Rs.50,000.

The  story in short is as under :-

2. The complainant insured himself under health insurance policy issued by O.P. on dated 26.10.2016 valid up to 25.10.2019 for the sum assured of Rs.4,00,000/-. The complainant undergone KNEE replacement HTN in   Nagpur at Mahajan Ortho and Surgical Hospital, Nagpur on dated 15.10.2019 operated on and incurred expenses of Rs.4,50,000/- and discharge from hospital on dated 18.10.2019.thereafter the complainant submitted the insurance claim with O.P. with relevant documents but the O.P. rejected the issuance claim for the reason of  pre-existing decease and its complication on dated 9.12.2019. The rejection of insurance claim is unsustainable ground therefore present complaint is filed.
3. The O.P. filed reply and denied the allegation made by complainant and admitted the insurance policy of complainant. O.P. issued insurance policy bearing no.10853335 from 26.10.2016 to 25.10.2019 for the sum assured of Rs.4,00,000/-. The O.P. further submitted in his reply that complaint is totally misconceived and not maintainable and proper authority to decide the matter is insurance ombudsman appointed by Insurance Development Authority Act, 1999.  On the basis of information furnishing in proposal form the O.P. issued Religare Health Care Policy to the complainant.  The complainant has not disclosed all material facts in proposal and mislead to the O.P.  The complainant insurance claim has been repudiated for the reason of exclusion clause-4 of the policy waiting period that claims will not be admissible for any medical expenses incurred for hospitalisation in respect of diagnosis /treatment of pre existing deceased until 48 months of continuous coverage has been laps since the instruction of trust policy therefore op rejected the claim as per denial letter dated 9.12.2019.  On the basis of 4 years waiting period for pre existing deceased and its complications therefore rejected of claim does not amount to deficiency in service hence complaint is deserve to be dismissed with cost.
4. Advocate Mr. Bhushan Deshmukh Counsel for complainant argued that the O.P. has rejected the insurance claim on filmily ground on 9.12.2019 as the complainant was examined by Doctor before issuance of policy and in medical examination no pre existing deceased traced has been detected before issuance of policy therefore rejection of claim amount to deficiency of service.
5. Advocate Mrs.Renuka Nalamwar, counsel for O.P. argued that the complainant was issued health insurance policy by O.P. bearing No.10853335 from dated 26.10.2016 to 25.10.2019  for the sum assured of Rs.4,00,000/- and renewed the policy dated 26.10.2019 to 25.10.2021. At the time of purchase of policy the complainant had disclosed pre-existing deceases of Benign Brain Tumour/ Internal was wrongly mentioned instead of Arthritis/Joint replacement and same was correct endorsement request by the complainant.  The complainant was diagnosis Osteoarthritis and underwent total Knee replacement. The complainant approached the company for reimbursement claim for medical reimbursement for the hospitalisation and operation at Mahajan Ortho and Surgical Hospital, from 15.10.2019 to 18.10.2019.  The O.P. raised a query on dated 5.11.20129 and asked to provide the information and documents for the past history of treatment papers for Knee Pain and hypertension and Osteoarthritis but complainant failed to submit all relevant documents.  The complaint has failed to disclose material fact regarding subject matter in question and trying to mislead the Commission by filling false and fabricated case. Therefore rejection of insurance claim for the exclusion clause under the policy does not amount to deficiency of service.

REASONING

6. The complainant has availed insurance policy namely ‘ Care’ being policy no.10853335 from dated 26.10.2016 to 25.10.2019 covering complaint and his wife for the sum assured of Rs.4,00,000/- and renewed from 26.10.2016 to 25.10.2021. The complainant on dated 15.10.2019 admitted at Mahajan Ortho and Surgical Hospital, Dhantoli, Nagpur for Knee Replacement surgery and after surgery the complaint had been discharged from hospital on dated 18.10.2019.
7. The complainant insurance claim has been repudiated by O.P. for reimbursement of medical expenses by rejection letter dated 9.12.2019 for the reason of exclusion clause.  As per discharge notes filed on record by complainant as per list of documents dated 28.10.2020 at serial no.35 in the coloum of history of patient it was mentioned that the complainant started pain and swelling in his both knees from one year ago but recently the pain has significantly increase in last few months and become virtually compound.  Both legs were in the form of blowing a bent knee his walking distance is less than a furlong, he has taken the treatment but little relief. The complainant had undergone treatment for swelling on pain legs on October 2017 at Rutika Clinic are casually treatment. The O.P. has failed to file the treatment papers on record for the treatment carried at Rutika Clinic.  The complaint had treated at Rutika Hospital as OPD patient. The complainant was not hospitalised or treated as indoor patient for long treatment for serious illness. Therefore there is no nexus treatment on October 2017 at Rutika Hospital with Knee replacement surgery or there is no evidence that because of O.P.D. treatment there is complications to the complainant and hs to undergo Knee replacement therefore
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suppression fact of casual treatment as a O.P.D. patient in Rutika Hospital does not amount to suppression of pre-existing decease and therefore rejection of insurance claim amount to deficiency in service.  Hence the complainant is entitled to receive the sum assured of Rs.4,00,000/- (Four Lac Only) towards insurance claim under the policy against the medical expenses for surgery bill paid Rs.4,50,000/- on 18.10.2019  to Mahajan Ortho and Surgical Hospital, Dhantoli, Nagpur as per following order.

ORDER

1. Complaint is partly allowed.
2. The O.P.–Insurance company is liable to pay Rs.4,00,000/- (Four Lac Only) towards medical expenses under the policy bearing No.l10853335 to the complainant.
3. The O.P.-insurance company is liable to pay Rs.20,000/- towards mental torture and cost of litigation to the complainant.
4. Copy of order be furnished to both the parties, free of cost.