DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH

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Vishal Jain r/o H.No.1407, Sec.15, Panchkula (Haryana)

              ---Complainant

Vs

1]   The Oriental Insurance Co. Ltd., SCO No.72-73-A, 2^nd Floor, Grain Market, Sector-26, Chandigarh, through its Branch Manager.

2]   Regional Manager, The Oriental Insurance Co. Ltd., SCO No.109-110-111, Sector 17-D, Chandigarh.

3]   Vipul Med Corp. TPA Pvt. Limited, 515, Udyog Vihar, Phase-V, Gurgaon (Haryana).

---- Opposite Parties

BEFORE:    MRS.MADHU MUTNEJA               PRERSIDING MEMBER

           SH.JASWINDER SINGH SIDHU        MEMBER

Argued By:    Sh. Sandeep Jain, Counsel for Complainant.

Sh. Vinod Chaudhri, Counsel for Opposite Parties No.1 & 2.

Opposite Party No.3 ex-parte.

PER MADHU MUTNEJA, PRESIDING MEMBER

1.          The Complainant had taken a medi-claim policy bearing No. 231300/48/2011/1815 (Happy Family Floater Policy) from Opposite Party No.1 valid from 20.10.2010 to 19.10.2011 for all his family members. A premium of Rs.14,549/- was paid. The policy covered hospitalization expenses for medical/ surgical treatment at any Nursing Home/ Hospital in India. The wife of the Complainant Smt. Renu Jain suffered from the disease “Accessory Navicular Syndrome”, for which she was operated upon in Medanta (The Medicity), Sector 38, Gurgaon, Haryana. A sum of Rs.91,656/- was paid. The Complainant has stated that when the bills were submitted for cashless facility, he was informed that the Opposite Parties were unable to issue any authorization for cashless treatment, as the disease was congenital and hence not payable under clause 4.8 of the policy. The Complainant has placed on record opinion of Dr. Balvinder Rana to prove his case that “Accessory Navicular Syndrome” was diagnosed only about six months back. Though the extra bone was present earlier, the patient was not aware of the condition till she developed pains six months ago. In fact, she had got one surgery done for this at her own cost in March, 2011. The Complainant has stated that this is not a Congenital condition but a developmental defect which seldom requires surgery. However, the Opposite Parties have rejected the claim filed. Alleging that denial of claim was unsustainable in the eyes of law, the Complainant has filed the present complaint with a prayer for payment of Rs.91,565/- (bills have not been attached), along with compensation, besides costs of litigation.

2.          Notice of the complaint was sent to Opposite Parties seeking their version of the case. However, despite service, nobody has appeared on behalf of Opposite Party No.3, therefore, it was proceeded against exparte on 14.09.2012.

3.          The Opposite Parties in their joint reply have stated that it is an admitted fact that the disease was pre-existing before the inception of the policy and hence the congenital disorder fell outside the ambit of insurance cover. The claim filed by the Complainant was processed and rejected in accordance with the norms of insurer, As per terms & conditions, exclusions and limitations of the policy. When it was discovered that the patient had a history of “Accessory Navicular Syndrome” which is a congenital disorder, the claim was rejected. Pleading that there was no deficiency in service on its part, Opposite Parties has prayed for dismissal of the complaint with costs.

4.          Parties were permitted to place their respective evidence on record in support of their contentions.

5.          We have heard the learned counsel for the Complainant and Opposite Parties No.1 & 2, Opposite Party No.3 being ex-parte and have perused the record.

6.          The grievance of the Complainant is that despite taking medi-claim policy (Happy Family Floater Policy), the cost incurred on the treat of his wife was not paid by the Opposite Parties. The relevant portion of the certificate (Annexure C-2) given by Dr. Balvinder Rana, is as under:-

“………Please note that the condition of Accessory Navicular Syndrome was diagnosed only about 6 months back. Though the extra bone present earlier, the patient was not aware of the condition till she developed pain 6 months back. Furthermore, she got one surgery done for this at her own cost in March, 11. Please note that this is not a congenital condition but a developmental defect which seldom requires surgery.” 

          The relevant portion of the letter of repudiation by the Opposite Parties at Annexure C-3, reads as under: -

“……The patient has Accessory Navicular Syndrome, which is a congenital disorder which is not payable as per the policy clause 4.8. Hence the claim is not payable which please note.”  

7.          The policy and the policy condition by which the claim can be allowed/ rejected have not been attached by either of the parties. The Opposite Parties have also not placed on record the certificate/ affidavit of the doctor who has opined that the disorder is a congenital disorder and hence the claim is not payable.

8.          To our mind, if the extra bone was already present earlier, but the patient was not aware of the condition till she developed pain for a surgery that was performed earlier, to treat the same at her own cost in March, 2011, the condition could perhaps be a congenital condition. But in the absence of any proof to substantiate this contention by the Opposite Parties, we can only believe the certificate (Annexure C-2) of the treating doctor, reproduced above, and allow the complaint.   

9.          In view of the foregoing discussion, we allow this complaint and direct the Opposite Parties, jointly and severally, as under:-

[a]  to make payment against the amount claimed as per the terms and conditions of the policy;

[b]  to pay a sum of Rs.5,000/- as costs of litigation.

10.        This order be complied with by the Opposite Parties within 45 days from the date of receipt of its certified copy, failing which, Opposite Parties shall be liable to pay the claimed amount to the complainant, besides Rs.5,000/- as costs of litigation.

11.        Certified copy of this order be communicated to the parties, free of charge. After compliance file be consigned to record room.

Announced

15^th January, 2013.                                                 

Sd/-

(MADHU MUTNEJA)

PRESIDING MEMBER

Sd/-

 (JASWINDER SINGH SIDHU)

MEMBER

“Dutt”