Adv. For the Complainant: - Sri D, Biswal and others
Adv. For O.P :- Sri P.K. Biswal
Date of filing of the Case :-18.01.2018
Date of Order :-27.05.2020
JUDGMENT
Sri A.K.Purohit, President
1. The complainant has preferred this case alleging deficiency in insurance service. The complainant has taken a PNB-Oriental Royal Mediclaim Policy from the O.P. on dated 10.8.16 which is renewed vide Policy No.345600/48/2018/590 and paid the premium amount of Rs.7173/-. The said policy is valid from 10.8.17 to 9.8.18 and covers the family members of the complainant. During subsistence of the said policy on dated 15.8.17 the wife of the complainant was admitted in the DHH hospital Balangir and after some test as per the advice of the doctor she was sifted to Continental Hospital Hydrabad for better treatment wherein she was treated as in-patient and paid Rs. 61431/- towards expenditure of the said hospital. To this the complainant lodge his claim before the O.P. claiming for an amount of Rs.76431/- showing all his expenditure towards treatment of his wife along with all relevant documents. The claim of the claim of the complainant was repudiated by the O.Ps. on the ground of non-admissibility of the claim. Hence the complaint.
2. Although notice has been served on O.P.1 & 3 neither they appears nor have proceeded with the case and hence they are set experte vide order dated 12.7.18. The O.P.No.2 contested the case by filing his written version. The O.P.2 admitted the policy and submitted that the complainant has suppressed the pre-existing disease and hence the complainant violated the policy conditions and is not entitled to the claim. The O.P.2 denied all other allegations of the complainant and claims dismissal of the case.
3. Heard both the parties. Perused the complaint petition, written version and documentary evidence available on record. It is evident from the policy document that the complainant had taken a PNB-Oriental Mediclaim Policy which is valid from 10.8.17 to 9.8.18 which covers the family members of the complainant. It is also evident from the report of the Hospital that the wife of the complainant Mrs. Mina Agrawal admitted in the continental Hospital as in-patient for the complain of severe abdominal pain associated with loose stool. It is seen from the copy of the claim form that, the complainant has duly lodge his claim along with all documents relating to his expenditure. It is seen from the letter dated 8/12/17 of O.P.2 that the claim of the complainant was rejected by applying the exclusion clues. With theses material available on record the point for consideration is whether the complainant is entitled to his claim for medical expanses or not.
4. It is seen from the letter dated 8.12.17 of the O.P. 2 that the claim of the complainant was rejected by applying 4.2.xvii of the policy exclusion wherein it has been mentioned that, waiting period for Hypertension disease is two years. This shows that the said exclusion clues is applicable for the disease of Hypertension. It is seen from the Hospital record that, the wife of the complainant was admitted for abdominal pain with loose stool and she was treated for the said disease. Hypertension is depends on physiological conditions and it varies from time to time and hence it is not a pre-existing disease. It may rise or fall due to abdominal pain and loose stool. There is no evidence available on record to show that, the wife of the complainant was treated for Hypertension at any point of time. The O.P. 2 has not filed any evidence either by way of affidavit or otherwise to show that she was treated for Hypertension. Hence the said exclusion clues is not applicable to this case.
5. The complainant has produce all the bills of the Hospital which shows that, the complainant has paid the amount and is entitled to reimbursement of hospitalization expanses. The O.Ps. are jointly and severally liable to pay the amount to the complainant as prayed for by the complainant. Hence ordered:-
ORDER
The O.Ps. are directed to pay Rs.76,431/- ( seventy six thousands and four hundred thirty one rupees ) jointly and severally to the complainant along with 6% interest P.A. from the date of repudiation i.e from 8.12.17 till payment within one month from the date of receipt of this order. There shall be no order as to cost.
Accordingly the case is disposed of.
Pronounced in the open Forum to-day the 27th day of May 2020.
Sd/- Sd/-
(S.Rath) (A.K.Purohit)
MEMBER. PRESIDENT
