DISTRICT CONSUMER DISPUTES REDRESSAL FORUM (CENTRAL) ISBT KASHMERE GATE DELHI

CC/220/2016

Sh. Avinash Kumar,

S/o Sh. Awad Kishor Singh

R/o H. No. 345, B-Block, Gali No. 17,

Durga Vihar Phase-II, Deen Pur,

Najafgarh, New Delhi.                                                           …..COMPLAINANT

VERSUS

United India Insurance Company Limited

Regional Office-1

8th Floor, Kanchanjunga Building,

18, Barakhamba Road, New Delhi.

Sir Ganga Ram Hospital

Chairman & Managing Director

Regd. Office: Sir Ganga Ram Hospital Marg

Rajender Nagar, New Delhi.                                              …..OPPOSITE PARTIES

Coram  :     Ms. Rekha Rani, President

                  Ms. Manju Bala Sharma, Member

                  Dr. R.C. Meena, Member

ORDER

Ms. Manju Bala Sharma, Member

1. Instant complaint has been filed by the complainant under Section 12 of the Consumer Protection Act alleging therein that complainant purchased cashless family mediclaim policy for his parents from OP1 vide policy number 042382/48/14/06/00000319 valid from 15.09.2014 to 14.09.2015. On 20.11.2014, at about 10 PM, the mother of the complainant fell down from the stairs and got severe lower back pain in left lower limb. On 21.11.2014, complainant went to Sir Ganga Ram Hospital where complainant was advised for minute surgery in back. OP1 gave initial approval of Rs. 10,000/- for conservative treatment but did not pay any money to the hospital. Mother of the complainant was discharged on 24.11.2014 and complainant paid Rs. 1,40,181/- in total to the OP Hospital for her treatment.  Complainant filed the claim with OP1 but the same was declined with the remarks “as the final diagnosis, patient is suffering from degenerative disk disorder and policy is from 15.09.2014, hence, pre-existing illnesses and cashless cannot be given. Previous approval stands cancelled.”  It is further alleged that mother of the complainant had no pre-existing illness and the claim had arisen only because of thr fall from the stairs. Complainant made several phone calls and sent e-mails to OP1 but OP1 deliberately with malafide intentions and alterier motive did not make the payment to the complainant. Complainant sent legal notice dated 06.01.2016 to OPs but no reply has been received from OPs. Complainant prayed that OP1 be directed to approve the prayer made by the complainant along with interest @24% p.a., to pay Rs. 1,00,000/- as compensation towards mental agony and harassment suffered by complainant.
2. Notice was sent to OPs. In reply, OP1 admitted the issuance of family mediclaim policy to the complainant but denied the allegations contained in the complaint and stated that the claim rejected by it is justified as per exclusion clause no. 4.3 of the terms and conditions of the policy. It is further stated that at the time of taking the above said policy, the mother of the complainant was suffering from L-5 S-1 degenerative disk disease. As per discharge summary dated 27.11.2014 issued by OP2 this disease comes under the exclusion clause no. 4.3 of the terms and conditions of the policy. It is further stated that an amount of Rs. 10,000/- was initially approved as per preliminary approval to start the treatment conservatively which is always subject to revision/rejection on evaluation of detailed medical history on receipt of further papers. OP1 prayed that as per final diagnosis, mother of complainant was diagnosed with degenerative disk disorder and the policy is from 15.09.2014, hence pre-existing illness cannot be ruled out and cashless cannot be given, the rejection of the claim is justified and the complaint be dismissed with costs.
3. OP2 in its reply has submitted the fact of admission of the mother of the complainant in the alleged hospital from fall from stairs, complaint of lower back pain which was radiating in left lower limb aggravated while walking and relieved on rest. OP2 prayed that as the complainant has neither suffered any loss nor has been able to point out any deficiency in service of OP2, the complaint be dismissed qua answering respondent with exemplary cost.
4. In rejoinder to the reply of OP1 and OP2, complainant reiterated the facts stated in the complaint and denied the allegations contained in the reply respectively.
5. Affidavit of evidence has been filed by the parties.
6. We have heard Sh. S.C. Kumar, counsel for complainant, Sh. Ram Singh, counsel for OP1 and Sh. Subhash Kumar, counsel for OP2.
7. Complainant has taken a cashless family medical policy for his parents for the period 15.09.2014 to 14.09.2015. Counsel for complainant has argued that as mother of the complainant fell down from stairs at her house on 20.11.2014 at 10:00 PM she got injury and she got severe pain in lower rib and for that she was taken to OP hospital where minor surgery was advised by the doctor. The claim of the complainant has been repudiated by OP on the ground that as per the final diagnosis, the mother of the complainant was suffering from degenerative disk disorder and since the policy is from 15.09.2014, hence, pre-existing illness cannot be ruled out and the policy was taken with the concealment of pre-existing disease and true facts were not disclosed by the complainant. Counsel for OP has relied upon the exclusion clause 4.3 which reads as under:

“Unless the Insured has 24 months of continuous coverage, the expenses on treatment of diseases such as Cataract, Benign Prostatic Hypertrophy, Hysterectomy for Menorrhagia or Fibromyoma, Hernia, Hydrocele, Congenital internal disease, Fistula in anus, piles, Sinusitis and related disorders, Gall Bladder Stone removal, Gout & Rheumatism, Calculus Diseases are not payable”.

8. Counsel for OP has argued that on perusal of the discharge summary of the mother of the complainant, it is specifically written ‘L-5 S-1’ degenerative disk disorder and in the medical history it is mentioned that the patient had lower back ache radiating to left lower rib and that patient was admitted with the complaint after the episode of fall from the stairs. In the discharge summary except the complaint of lower backache radiating to lower left rib after the episode of fall from stairs. No swelling and fracture in any part of the body due to the fall is found. MRI report of Lumbar of Spondylosis spine AP and Lateral view reads as under:

“Lumbar Spondylosis is a spine condition that describes the natural deterioration of the lower spine die to age and compression.While Spondylosis can occur throughout the spine, the post common location of occurrence is in the lowest portion of the spine.Spondylosis changes in the spine are frequently referred to as osterarthitis.For example the phrase “spondylosis of the lumbar spine” means degenerative changes such as osteoarthritis of the vertebral joints and degenerating intervertebral discs (degenerative disc disease in the low back.”

9. No swelling or compression is shown in the MRI of the Lumbar of Spondylosis spine of the mother of the complainant. In case a person falls from the stairs, it ought to have some swelling or compression on the other parts of the spine.
10. Instant policy was effective from 15.09.2014 to 14.09.2015. OP1 had clearly pleaded that since in the discharge summary the doctor has diagnosed degenerative disk disease and it does not find any mention of any other injury due to fall from the stairs, the claim of the complainant is not justified and is covered under clause 4.3 of the terms and conditions of the policy. Counsel for complainant has relied upon judgment of Hon’ble National Commission in Nirmalaben Jayshukhla Seth vs. New India Assurance Company Ltd. (RP No. II (2008) CPJ 51 (NC)), the facts of which are different from the facts in the instant case.  In the instant case cited by the counsel for complainant, the complainant accidentally fell which resulted in fracture to her hip after which she felt significant discomfort and was operated for the same. In the instant case neither in the discharge summary nor in the MRI any other injury due to fall from the stairs finds place. The mother of the complainant is 51 years of age and at this stage of age degenerative changes are obvious in one’s body.
11. In view of the above discussion, the claim of the complainant is not justified and is rightly repudiated by OP as the same was claimed within 2 months from the date of issuance of the policy and is barred by exclusion clause 4.3 of the terms and conditions of the policy.  The complainant is dismissed.   Copy of this order be sent to the parties as statutorily required. File be consigned to record room.

Announced this           day of                       2019.