Sri Shyamal Gupta, Member

This Appeal is directed against the Order dated 21-04-2015 passed by the Ld. District Forum, Kolkata, Unit I in C. C. No. 487/2012 whereby the complaint has been dismissed.

Case of the Complainant, in a short compass, is that while opting for the Mediclaim Policy in the year 2010, he duly apprised the agent concerned about his past medical history to that of installation of Pacemaker on 18-06-2004 and based on such information, the concerned Agent duly noted the same in the proposal form.  It is the further case of the Complainant that at that time he was assured by the said agent that since the same was done 6 years ago, it would not pose any hindrance in getting insurance benefit under the policy and based on such assurance, he paid due premium.  Allegedly, when the hospital bill pertaining to replacement of his pacemaker was sent to the OP Insurer, it refused to reimburse any payment thereof.  Hence, the case.

The case of the OP Insurance Company, on the other hand, is that the Insured cannot claim anything more than what is covered by the insurance policy.  It is stated that on due inspection of the claim bills it was revealed that the Insured was treated for replacement of the pacemaker during his overseas trip.  It also revealed from the medical records that the pace maker was placed on 18-06-2004 and the Insured was on regular check up related to the same.  The treatment taken abroad by the Insured was related to the above mentioned treatment taken by the Insured in India since 2004 which was prior to the policy effective date, i.d., 17-05-2010.  It is further stated that as per policy exclusion, “the policy does not provide benefit for any expenses incurred directly or indirectly in respect of any pre-existing condition or any complication arising from it”.  Accordingly, claim of the Complainant was rightly repudiated.

The moot point for consideration is whether the impugned order is justified or not.

Decision with reasons

Admittedly, the Appellant underwent pacemaker implant on 18-06-2004 and the insurance policy in question was effective from 17-05-2010.  It is also not in dispute that the claim was lodged for replacement of the pacemaker. 

According to the Respondent, pre-existing disease of the Appellant stood in the way of settlement of his claim. There cannot be any doubt as to fact that terms and conditions of an insurance policy is sacrosanct and the same is equally binding on both sides. On the face of it, one may tend to give benefit of doubt to the Respondent.  The irony, however, is that all too often what seems a bona fide decision, the same falls apart when subjected to little scrutiny. 

Pre-existing Condition is defined as under in the insurance policy.

“Pre-existing Condition – a condition for which care, treatment or advice was recommended by or received from a Physician or which was first manifested or contacted within two years period preceding the Policy Effective Date of Coverage, or a condition for which hospitalization  or surgery was required within a five year period preceding the Policy Effective Date specified in the Schedule”.

Going by this stipulation, cooling period for pre-existing diseases has been restricted to two/five years.  Since the Appellant underwent pacemaker implant six years preceding the policy effective date, he certainly did not fall into the exempted category.  Further, although it is alleged by the Respondent that the Appellant was on regular check up related to the pacemaker which was implanted in the year 2004, not a scrap of paper is placed on record from its side to support such contention.  Despite this we find that the Respondent, in a bid to repudiate the claim by hook or by crook, only dished out half-truth and straightway repudiated the claim of the Appellant.  There is no reason to believe that the Respondent was unaware of policy terms and conditions, more precisely, the definition of pre-existing condition as contained in the policy schedule.  Still that the claim of the Appellant was most arbitrarily repudiated only manifests gross deficiency in service on the part of the Respondent.

As the terms and conditions of the insurance policy is equally binding on the Respondent vis-à-vis Appellant, the Respondent cannot abdicate its contractual responsibility to settle the legitimate claim of the Appellant. 

The manner in which Respondent thumped down the insurance claim of the Appellant only reinforces the perception amongst public at large that arbitrariness is the DNA of Insurance Companies.  Such a perception has not been conjured out of thin air.  Repudiation of claims by Insurance Companies is so rampant that a great amount of distrust has developed in between Insurers and Insurees.  Instances like the present one certainly does not augur well for the Insurance Sector.

Needless to say, the Ld. District Forum went totally wrong in adjudicating the dispute.  That being so, the impugned order is not tenable.

Consequently, the Appeal succeeds.

Hence,

O R D E R E D

that A/582/2015 be and the same is allowed on contest against the Respondent Insurance Company.  The Respondent is directed to reimburse equivalent sum of US$ 15,932.24 (US$16,032.24 – US$ 100) in Indian currency as per exchange rate applicable on the date of payment and compensation for a sum of 50,000/.  The Respondent is directed to comply with this order within 45 days hence. The impugned order is hereby set aside.