ORDER

Per NIPUR CHANDNA, MEMBER

        Complainant is the mediclaim policy holder of the OP vide policy no. 272302/48/2011/1116 w.e.f. 4/11/2010 to 3/11/2011. It is alleged by the complainant that on 11/5/2011 his wife was admitted  in Maharaja Agarsen Hospital for management of uterine prolapse and was discharged on 16.5.2011. It is further alleged by the complainant that on 01/6/2011 he had lodged a claim of Rs. 75,100/- with the OP vide claim no. 01/NDO/52011/15853682.  It is alleged by the complainant that after lodging  the claim with the OP, the complainant approached the OP for the payment of the same, but the OP postponed the matter under one pretext or the other.  It is further alleged by the complainant that instead of making payment of the claim amount, OP had repudiated his claim on false and flimsy ground.  Thereafter complainant wrote several letters to the OP requesting it for the reimbursement of the claim, but nothing had been done by the OP till date.  The complainant, therefore, approached this forum for the redressal of his grievances.

  OP has contested the complaint and has filed a written statement.

   Para no. 2 and 3 of the preliminary objections of the written statement are relevant for the disposal of this complaint and are being reproduced as under:-

2.At the outset , the present complain is liable to be dismissed in view of the fact that as per the medical documents/ records of Smt. sunita Sharma , the patient was admitted for management of uterine prolapse on 11-5-2011 and discharged on 16-5-2011. Upon scrutiny of the documents, it is quite apparent that the patient was having this ailment for 3-4 years. Although, the policy  was since 20-9-2003, but there is a break-in policy. One policy was from 20-9-2008 to 19-9-2009 and the next policy was from 4-11-2009 to 3-11-2010. As per the rules of mediclaim policy will be considered the subsequent policy as fresh policy.  As per the rule, the policy started from 4-11-2009 to 3-11-2010 , whereas, the ailment above mentioned has been in existence for the past 3-4 years from the hospitalization i.e. 11-5-2011, thus, making the ailment as pre-existing disease.

3. That thus, it is crystal clear that the patient was having a pre-existing disease which is in violation of the exclusion clause 4.1 of the mediclaim policy and condition 5.5 of the mediclaim policy. The clause 4.1 states as under:-

“Pre-existing health condition or disease or ailment /injuries:

Any ailment / disease / injuries/ health condition which are pre-existing (treated/ untreated, declared / not declared in the proposal form), when the cover incepts for the first time , are excluded for such insured person up to 4 years of this policy being in force continuously.”

It is also stipulated in the said clause that “This exclusion will also apply to any complications arising from preexisting ailments/ diseases/ injuries. Such complications shall be considered as a part of the preexisting health condition of disease”.

M/s E-Meditek (TPA) Services Ltd. has rightly repudiated the claim of the complainant. The repudiation letter dated 22-6-2011 of OP1 is annexed hereto as Annexure-A.

    We have heard arguments advanced at the bar and have perused the record.

    The learned counsel for the OP has taken us through the copies of mediclaim policies filed by the complainant along with his complaint. The bare perusal of the policy  shows that although the policy was taken for the first time w.e.f. 20-9-2013 and had been renewed  there is a break in the subsequent renewals. The policy renewed in the year 2008 is the policy from 20.9.2008 to 19.9.2009 , whereas the next policy was purchased on 4-11-2009 and is valid upto 3/11/2010. As per the rules of mediclaim policy, any break in policy from year to year  will be considered to be a fresh policy.

  The counsel for the OP has drawn our attention towards the discharge summary which clearly speaks that the patient was suffering from the present ailment for the past 3-4 years, thus making the ailment as pre-existing disease.

   The counsel for the OP has contended that since the patient was suffering from the ailment for the past 3-4 years  , and there is a break in the policy, hence the present ailment are excluded under clause 4.1 and 5.5 of the policy terms and conditions.  He has contended that the claim was rightly repudiated by the OP as per the terms and conditions of the policy.

We are in agreement with the contentions of the counsel for the OP.  There is a break in policy which makes the mediclaim policy afresh coming into force w.e.f. 4-11-2009 to 3-11-2010. We are , therefore , of the considered opinion that the claim had been rightly repudiated in view of the terms and condition of the mediclaim policy as alleged. We see no merits in this complaint. The same is hereby dismissed.

The OP shall pay this amount within a period of 30 days from the date of this order failing which they shall be liable to pay interest on the entire awarded amount @ 10% per annum.  IF the OP fails to comply with this order, the complainant may approach this Forum for execution of the order under Section 25/27 of the Consumer Protection Act.

    Copy of the order be made available to the parties as per rule. 

    File be consigned to record room.

    Announced in open sitting of the Forum on.....................