Per Shri Narendra Kawde – Hon’ble Member:
(1) This complaint has been filed alleging deficiency in service against the Opponent – The New India Assurance Co. Ltd. (Hereinafter referred to as ‘the Insurance Company’) for not settling mediclaim of the Complainant under the mediclaim policy. It is stated by the Complainant that she has subscribed to mediclaim policy bearing No.4817/2500/00016.4, jointly with her husband with the sum assured of `3,00,000/-. The Complainant was hospitalized on 07.12.1998 i.e.during the validity period of the mediclaim policy and underwent coronary bye-pass surgery to remove suspicious clot detected during the course of angiography and was discharged on 18.12.1998. The Complainant filed mediclaim with the Insurance Company for reimbursement of hospital expenses of `2,56,000/-. The Insurance Company repudiated the mediclaim of the Complainant on the ground that the Complainant had pre-existing disease for last two years prior to hospitalization in December, 1998. This repudiation was based on the expert opinion of the panel doctor of the Insurance Company. Aggrieved with this repudiation the Complainant preferred this complaint.
(2) Opponent Insurance Company denied the contention of the Complainant by filing written version and affidavit of evidence and relied on medical summary obtained through investigator. Further averred that repudiation is justified as the panel Doctor’s opinion is on record to show that Complainant had pre-existing chest pain.
(3) This is an old matter placed on board for hearing and disposal. Heard the Ld.Advocate for the Complainant. The Opponent Insurance Company preferred to remain absent at the time of hearing.
(4) It was submitted by the Ld.Advocate for the Complainant that the Complainant has been regularly subscribing for medicalim policy w.e.f. 1st February, 1997 till 31st January, 1999. The Complainant for the first time developed chest pain somewhere in November, 1998 and on advice of the Family Doctor she was referred to the expert for further examination, who suggested treatment for external angina, which developed since last four months. The Complainant underwent coronary angiography on or about 16.11.1998 and as advised by the expert doctor underwent coronary bye-pass surgery at Lilavati Hospital where she was admitted during 07.12.1998 to 18.12.1998. Prior to that Complainant underwent routine thorough medical examination in Hinduja National Hospital, Mumbai on 02.12.1997 for special health check-up which was reported to be normal and no abnormality was noticed in respect of the chest pain. The Opponent Insurance Company obtained the medical summary from Lilavati Hospital in respect of the Complainant and referred the said summary to panel doctor for expert opinion. This expert opinion based on the medical summary obtained through investigator is placed on record given by one Dr.P. Mutthuswami on 21.01.2000 and on the basis of this expert report the Opponent Insurance company repudiated the mediclaim on 31.03.2000 which is erroneous and contrary to the fact as the Complainant never suffered chest pain prior to subscribing to the mediclaim policy. The health check-up report dated 02.12.1997 of Hinduja National Hospital did not show any abnormality and the Respondent Insurance Company wrongly repudiated the mediclaim insurance of the Complainant.
(5) We have perused the record and documents tendered by the parties. Admitted facts on record are that the Complainant jointly with her husband continuously subscribed to mediclaim policy with a cap of `3,00,000/- as sum assured. There is no dispute that the Complainant was required to be admitted for undergoing coronary bye-pass surgery in Lilavati Hospital for which she was hospitalized during the period 07.12.1998 to 18.12.1998. Expenditure of `2,56,000/- was incurred on account of hospital expenses. The claim was filed thereafter for reimbursement, however, the claim was repudiated by the Opponent Insurance Company holding that the Complainant had pre-existing disease of chest pain prior to issue of policy on 01.02.1997.
(6) The Respondent Insurance Company relied on medical summary obtained from Lilavati Hospital and the expert opinion thereon from the panel doctor holding that the Complainant had chest pain since last two years, i.e. prior to subscribing to the mediclaim policy. The medical summary obtained through investigator which is disputed by the Complainant. The Opponent Insurance Company has not filed this report as a documentary evidence as required under section 13(4) of the Consumer Protection Act, 1986, so also the expert report of the panel doctor based on medical summary of December, 1998 is not tendered as a documentary evidence as required under section 13(4) of the Consumer Protection Act, 1986. Therefore, the decision of repudiating the claim based on these experts opinion cannot be taken as validly acted upon. Complainant in her affidavit of evidence stated that she had never sustained chest pain prior to issuance of the said Insurance Policy by the Opponent and further she underwent heart check-up at Hinduja National Hospital on 02.12.1997 did not mention about any such cardiac trouble. There is no rebuttal evidence on behalf of the Opponent Insurance Company.
(7) we have considered this case in its entirety and hold that the Opponent Insurance company rendered deficiency in service by repudiating the mediclaim of the Complainant arbitrarily. We hold accordingly and pass the following order:
O R D E R
(i) Complaint is partly allowed.
(ii) Opponent – the Insurance Company is directed to pay compensation of `2,56,000/- to the Complainant along with interest @9% per annum from the date of repudiation of claim i.e. from 31/03/2000 till its realization.
(iii) Opponent to pay costs of `25,000/- to the Complainant and bear its own costs.
Pronounced on 9th February, 2012.
