Rajasthan

StateCommission

A/690/2016

Diliph Verma s/o Lat. Narsingh Lal - Complainant(s)

Versus

Star Health & Allied Insurnace Co. Ltd. - Opp.Party(s)

Adarsh Verma

01 Jun 2017

ORDER

BEFORE THE CONSUMER DISPUTES REDRESSAL COMMISSION,RAJASTHAN,JAIPUR BENCH NO.1

 

FIRST APPEAL NO: 690 /2016

 

Dilip Verma s/o late Narsingh Lal r/o 134 Arya Nagar, Murlipura, Jaipur.

Vs.

Star Health & Allied Insurance Co. Ltd., KRM Centre, 6 floor No.2 Herigton Road Chetpat, Chennai & ors.

 

Date of Order 1.6.2017

Before:

Hon'ble Mrs. Justice Nisha Gupta- President

 

Mr. Alok Fatehpuria counsel for the appellant

Mr.S.S.Khandelwal counsel for the respondents

 

BY THE STATE COMMISSION ( PER HON'BLE MRS. JUSTICE NISHA GUPTA,PRESIDENT):

 

This appeal has been filed against the order passed by the District Forum, Jaipur 4^th dated 25.5.2016 whereby the claim has been dismissed.

 

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The contention of the appellant is that previously he was insured with Sahara India since April 2008 and he suffered on 21.5.2012 after the locking period of 48 months. The disease was not pre-existing. He suffered first time on 21.5.2012 hence, the claim should have been allowed.

 

Per contra the contention of the respondent is that the appellant was insured only in April 2010 and as per exclusion clause for pre-existing disease claim was not allowable until the lapse of 48 months and appellant was suffering from pre-existing disease hence, the claim has rightly been disallowed and Group Insurance Policy cannot be port with.

 

Heard the counsel for the parties and perused the impugned judgment as well as original record of the case.

 

There is no dispute about the fact that earlier the appellant was insured with Sahara India since April 2008. The contention of the appellant is that in 2010 he purchased the impugned policy and exclusion clause clearly mandates that 48 months would be calculated since inception of first policy with any indian insurer and in the present case he was insured since April 2008 which lapsed in April 2012 and admittedly he

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suffered in May 2012 hence, the insurance company could not get shelter of the exclusion clause.

 

The contention of the insurance company is that the earlier policy was Group Insurance Policy as the appellant was the employee of the Sahara India and as per portability of health insurance guidelines only individual/family policies could be port. Be that may be the case, here in the present case the exclusion clause clearly provides that calculation of 48 months would be started since inception of first policy with any indian insurer and there is no limitation to the effect that group policies would not be included in the above clause and there is no dispute about the fact that with previous insurer the appellant was insured since April 2008 and after lapse of 48 months he suffered the disease. Hence, insurance company could not take shelter of the exclusion clause.

 

The other contention of the appellant is that he was not suffering from any pre-existing disease as he first time suffered from the disease on 21.5.2012 and admitted to Medanta Hospital, Gurgaon.

 

The contention of the respondent is that the appellant was

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suffering from Congenital Bicuspid Aortic Valve and as per opinion of Dr. Manu Ganda the size of aortic aneurysm was 5.5 c.m. and normally it grows 0.16 c.m. per year which shows that the disease was much prior to inception of policy and contention of the respondent is that the insured was suffering from pre-existing disease but admittedly the respondent has not come with any tangible evidence to show that the appellant was suffering from any disease prior to purchase of the policy. Dr. Manu Ganda has only given the opinion as about the growth of the disease which generally occures in the matter but nothing has been brought on record which could show that the appellant was suffering from the disease prior to inception of the policy or he was having any symptoms of the disease. If the appellant was not knowing about the disease it cannot be said that he was suffering from any disease prior to purchase of the policy and mere opinion as regard of disease cannot be take place of the proof and in view of the above the findings of the Forum below could not be sustained.

 

The appeal is allowed and the respondent is directed to pay the claim amount alongwith 9% interest from the date of

 

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presentation of the claim. The appellant will further get Rs.11,000/- for cost of proceedings. The order should be complied within two months.

 

(Nisha Gupta) President

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