Justice Pritam Pal, President 1. This appeal by complainants is directed against the order dated 11.9.2009 passed by District Consumer Forum-II, U.T. Chandigarh whereby their complaint bearing No.266 of 2009 seeking insurance claim under the mediclaim policy was dismissed. 2. The parties hereinafter shall be referred to as per their status before the District Consumer Forum. 3. In nutshell, the facts as set out in the complaint are that the Complainants had been continuously purchasing the mediclaim insurance policies from the OPs for the last about 8 years without concealing any fact regarding the status of their health. The latest policy purchased by them was for the period from 16.3.08 to 15.03.2009 covering both the complainants for a sum assured of Rs.1,00,000/- each. In the year 2002 Smt.Pushpa Walia, complainant No.2 suffered illness relating to her right knee and she got treatment for the said ailment. The claim was made for reimbursement which was allowed by OPs. During the continuation of the latest policy, the complainant No.2 again fell ill and she was got admitted in Dhawan Hospital where she was operated upon and her right knee was replaced. She remained admitted in the said hospital from 12.11.08 to 18.11.08 where she spent about Rs.2,52,250/- on her treatment. She submitted her claim for reimbursement under the insurance policy alongwith all requisite documents but the claim was repudiated by OPs vide letter Annexure C-9 on the ground that the claim was barred by exclusion clause 4.1 of the policy. It was alleged that the repudiation of the claim was illegal and unjust. Hence, alleging deficiency in service on the part of insurance company, complainants filed complaint before the District Forum seeking reimbursement of medical expenses under the policy besides compensation and costs. 4. On the other hand, the case of OPs NO.1 & 2 before the District Forum was that the claim of complainants had been rightly repudiated as at the time of purchasing the policy, the proposer had to disclose all the diseases/treatments undergone by him/her but the complainants never disclosed the fact that the complainant No.2 was suffering from Arthosis of Knee since,2002. The medi-claim policies were taken from OPs for the year 2004-05,2006-07, 2007-08, 2008-09 by concealing the factum of knee disease which was in the knowledge of complainant with effect from the year 2002 and had been enjoying ‘no claim bonus’ which benefit is being given to the policy holder when no claim is made under the previous policy. As the complainant NO.2 was suffering from the said disease for which she got treatment even prior to obtaining the insurance policy in question, so her claim had been rightly repudiated in view of the exclusion clause No.4.1. It was pleaded that there was no deficiency in service and a prayer was made for dismissal of the complaint. OP No.3, however, did not appear before the District Forum and suffered ex parte proceedings. 5. The District Consumer Forum after going through the evidence and hearing the counsel for the parties came to the conclusion that the complainant had failed to make out any case of deficiency in service and dismissed the complaint. Still dissatisfied , complainant has come up in this appeal. 6. We have heard learned counsel for the parties and gone through the file carefully. It was argued on behalf of the appellants/complainants that Mrs.Pushpa Walia was earlier operated for illness of her right knee as per discharge card dated 7.8.2002 much beyond the 48 months and as such clause 4.1 of the policy does not apply to their case. Further they had been taking insurance policies for the last more than 48 months and the left knee of Mrs. Pushpa suffered illness during the period of policy from 16.3.2008 to 15.3.2008 and as such she did not conceal any fact relating to her health status while purchasing the policy in question. However, these points of arguments have been repelled by the learned counsel for insurance company by stating that the complainants had obtained insurance policy for the first time in the year 2004 after complainant NO.2 got treatment for his right knee but she did not disclose the said disease at the time of taking policy. 7. It is pertinent to mention here that the complainant No.2 was suffering from illness of her both knees which required replacement and she was admitted on 11.11.2008 with Dhawan Hospital,Panchkula where she was operated and discharged after hospitalization on 18.11.2008. Thus, the claim for reimbursement was submitted under the insurance policy which was effective from 16.3.2008 to 15.3.2009. Annexure R-2 is the medical record (progress sheet of the patient) regarding treatment of the complainant No.2 in the Dhawan Hospital wherein it is recited that the patient ( complainant No.2) was having a history of pain in her right knee for the last more than 2-3 years. Thus, at the time of purchasing the policy for the year 2008-09,she was aware of the fact that she was suffering from the knee problem but she did not disclose this material fact. So this material fact was concealed by her at the time of obtaining the insurance policy in question. Clauses-4.1 and 4.3 of the insurance policy annexure R-1 are relevant to be reproduced here as under ; “Exclusions: The company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of:- 4.1 Any pre-existing conditions as defined in the policy, until 48 months of continuous coverage of such insured person have elapsed since inception of his /her first policy with the company. 4.2 Xxxxx 4.3 During the first two years of the operation of insurance cover, the expenses on treatment of diseases such as Cataract, Benign Prostatic Hypertrophy Hysterectomy for Menorrhagia or Fibromyoma, Hernia, hydrocele, congenital, Internal diseases, Fistula in anus, Piles, sinusitis and related disorders, gall bladder stone removal, Gout and Rheumatism, Calculus Disease, joint replacement due to degenerative condition and age-related osteoarthiritis and Osteoporosis are not payable. If these disease (other hand congenital internal disease) are pre-existing at the time of proposal they will not be covered even during subsequent period of renewal too. If the inured is aware of the existence of congenital internal disease before inception of policy, the same will be treated as pre-existing”. 8. A perusal of clause 4.1 reproduced above reveals that the insurance company was not liable to pay any amount under this policy if any pre-existing condition as defined under the policy until 48 months of continuous coverage of such insured person had elapsed since inception of his policy with the company. According to clause 4.3 the pre-existing disease (other than congenital internal disease) at the time of proposal would not be covered even during the subsequent periods of renewal. In the instant case, the complainant No.2 was having the knee problem even at the time of obtaining the insurance policy in question, so,she was not entitled to get reimbursement of the medical expenses under the policy and Distirct Forum rightly exonerated OP insurance company from the allegation of deficiency in service and dismissed the complaint. 9. In view of the foregoing discussion, we are of the considered opinion that there is no illegality in the impugned order dated 11.9.2009 passed by the District Forum which is well reasoned and requires no interference. Accordingly the appeal fails and same is hereby dismissed, leaving the parties to bear their own costs. Certified Copies of this order be sent to the parties, free of charge. The file be consigned to record room.
| | HON'BLE MRS. MRS. NEENA SANDHU, MEMBER | HON'BLE MR. JUSTICE PRITAM PAL, PRESIDENT | , | | 
