Complainant through Lrd. Adv. Sawant

Opponent No. 1 and 2 through Lrd. Adv. Maheshwari

Per : Mr. V. P. Utpat, President              Place   :  PUNE

                                     J U D G M E N T 

                                         05/07/2014                                                                                                

          This complaint is filed by the consumer against the Insurance Company for deficiency in service under section 12 of the Consumer Protection Act, 1986.  The brief facts are as follows.

1]       The complainant is resident of Bhivadi, Taluka – Purandre, District – Pune.  The opponent no. 1 and 2 are the Branch office and Head office of the insurance company, situated at Pune and Chennai respectively.  The opponent no. 3 is the Agency, which is dealing in the settlement of the claim.  It is the case of the complainant that, he has obtained insurance policy firstly in the month of January 2006 and the said policy was renewed from time to time till 26/08/2010.  According to the complainant, he was admitted in Jehangir Hospital on 08/01/2010 and after taking treatment, he was discharged on 21/01/2010.  He had requested for cashless treatment.  But his claim was rejected by the opponent.  Thereafter he has paid bill of Rs.51,374/- and submitted his mediclaim to the opponent.  However, this claim was repudiated by the opponent on the ground that it is a fresh policy and the claim is made for pre-existing disease and it is not allowed as per clause no. 4.1 of the insurance policy.

          According to the complainant, as his policy was continuous, there was no any pre-existing disease and he had not obtained fresh policy at the time of submitting the mediclaim.  Repudiation of the insurance claim amounts to deficiency in service.  Complainant has prayed for payment of Rs. 56,374/- along with interest @ 18% p.a.

2]      The opponent resisted the complaint by filing written version, in which it has denied the contents of the complaint in toto.  It is flatly denied that the policy was obtained in the year 2006 and it was renewed from time to time.  It is also denied that the mediclaim of the complainant was wrongly repudiated.  According to the opponent, the complainant had obtained policy for the first time on 27/08/2009 and it was valid up to 26/08/2010.  He had approached to doctor on the same day i.e. on 27/08/2009 and the diagnosis of his disease was “Lumber Canal Stenosis”.  According to the opponent, it can not be an acute condition.  This is a chronic ailment i.e. pre-existing in nature.  Hence, the opponent has rightly repudiated the mediclaim of the complainant.  The opponent has prayed for dismissal of the complaint.

3]      After scrutinizing the documentary evidence, which is produced before this Forum, hearing the arguments of both the counsels and considering pleadings, the following points arise for the determination of the Forum. The points, findings and the reasons thereon are as follows-

REASONS    :-

4]      It is the case of the complainant that he has obtained policy from the opponent since January 2006 and it was renewed from time to time.  However, the complainant had not produced previous policies, which was obtained by him from the opponent, even though, the opponent has flatly denied about this fact.  The only policy, which is on record, is for the period of 27/08/2009 to 26/08/2010.  It further reveals that the complainant had approached to doctor on 27/08/2009 i.e. on the same day on which he had obtained the policy.  According to the opponent, being a fresh policy, said can not be accepted.  It is also contended by the opponent that, as the complainant was suffering from “Lumber Canal Stenosis”, which is a chronic ailment and it should be presumed that such ailment was existing with the complainant prior to obtaining the policy.  The complainant has not submitted any satisfactory explanation about not producing renewed policies.  In such circumstances, this Forum is of the opinion that the opponent has rightly repudiated the mediclaim of the complainant, as the disease of the complainant was pre-existing and the complainant had submitted mediclaim for the treatment, which was taken by him within six months from the issuance of the policy.  In this regard, this Forum is of the opinion that there is no deficiency in service on the part of the opponents and the complainant is not entitled for any compensation.  In the result, this Forum answer the points accordingly and pass the following order.

O R D E R

1. The complaint is dismissed with no

order as to the costs.

                   2.       Copies of this order be furnished to

the parties free of cost.

3.       Parties  are directed to collect the sets, which were provided for Members within one month from the date of order, otherwise those will be destroyed.