ORDER
Complaint under Sec.12 of the CPA 1986 as amended upto date
Per Sh. Rakesh Kapoor, President
The complainant has purchased a “Happy Family Floater Policy Scheduly (Gold Plan) Mediclaim policy from OP -1/OP -2. It is alleged that on 13.4.2013, the mother of the complainant ( one of beneficiaries under the policy) was admitted in the St. Stephen Hospital Delhi as she was feeling uneasy in taking breath. She was discharged from the Hospital on 6.5.2013. The complainant had incurred a sum of Rs.2,08,410/- on account of the treatment of her mother. He had lodged a claim with the OP which was repudiated by it. The complainant has alleged that the repudiation of the claim was illegal and unwarranted. Hence, the complaint.
The OPs have contested the complaint and have filed a written statement. They have denied any deficiency in service and have claimed that the complaint is without merits and is liable to be dismissed.
Para 7 of the W.S. of the OPs are relevant and is re-produced as under:-
7. That the complainant has not approached this Hon’ble court with clean hands and suppressed the material facts before the Hon’ble Court. The complainant is well aware that the claim is not payable by the answering OP . Even then the complainant chosses to harass the answering OP .
The brief facts leading to the present case are as follows:-
- That the complainant has taken a Happy Family Floater Insurance Policy for the period of 13.7.2012 vide policy bearing No. 212200/48/2013/748 subject to term and conditions of the policy.
- That on 15.5.2013 the complainant submitted the documents and after receiving the said documents, the Respondent 1 and 2/OP processed the claim and after the process it has been revealed that the claim of the claimant is not admissible as per the clause of 4.3 of the policy.
- The mother of the complainant was admitted in the hospital as a k/c/o HTN with DM with CVA underwent conservative treatment.
- and amputation of rt big toe done and discharged with follow up advice. It was clarified to the complainant that in the first year as per clause 4.3 DM HTN falls under two years exclusion, hence the claim of the complainant was repudiated.
- As per clause 4.3 during period of Insurance Cover, the expenses on treatment of following ailment/disease/surgeries for specified period are not payable. It contracted and/or manifested during the currency of the policy. Benign ENT disorders and surgeries i.e. Tonsillectomy, Adenoidectomy, Mastiodectomy, Tympanoplasty etc.2 years.
We have heard arguments advanced at the Bar and have perused the record.
The complainant has placed on record a discharge summary in respect of his mother which was prepared in St. Stephen Hospital on 6.5.2013. It records the diagnose of the patient as old CVA/DM type 2/SEPSIS (IMPROVED) ACS WITH LVE/SCLEROTIC AORTIC VALVE/CAD RIGHT DIABETIC FOOT (AMPUTATED BIG TOE)
It is, therefore, clear that the patient was suffering from diabetes and Hypertension at the time of admission in the hospital, Not only that, she was also suffering from a diabetic foot and her big toe of right foot was amputated in the hospital. As per Exclusion Clause 4 of the policy of insurance purchased by the complainant, expenses incurred on the diseases relating to diabetes and Hypertension are not payable. In the present case the patient had suffered from Cerebro Vascular accident and Coronary Artery Disease which are also related to diabetes and Hypertension. Expenses incurred on the treatment of diseases relatable to Hypertension and diabetes are not payable during the first year of the currency of the policy. In our opinion, therefore, the OPs had rightly repudiated the claim under the Exclusion Clause. We do not see any merit in this complaint. The same is hereby dismissed.
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.....................
(NIPUR CHANDNA) (DR. VIKRAM DABAS) (RAKESH KAPOOR) MEMBER MEMBER PRESIDENT
