Haryana

StateCommission

A/646/2018

BAJAJ ALLIANZ LIFE INSURANCE CO. - Complainant(s)

Versus

VIKRAM - Opp.Party(s)

VARUN CHAWLA

23 Jan 2019

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA

                                                                                 

                                                                  First Appeal No.646 of 2017                                                  Date of Institution: 25.05.2017                                                              Date of Decision: 23.01.2019

 

Star Health and Allied Insurance Company Limited, Branch Office Hisar, DSS 273, First Floor, Opposite Aggarsain Bhawan, Green Square Market, Hisar, District Hisar, through its branch Manager, through its  authorized signatory, M/s Star health and Allied Insurance Company Limited, 2^nd Floor, 13, Alipur road, Civil Lines, Delhi-110054, at present at Gautam Budh Nagar, Noida.

…..Appellant

Versus

Anil Kumar, aged 25 years, s/o Sh. Sh. Parveen, R/o H.No.513, Nimdia Pana, Village Rajli, Distt. Hisar.

                   …..Respondent

CORAM:             Mr. Ram Singh Chaudhary, Judicial Member.                                               Mrs. Manjula, Member

 

Present:              Shri Satpal Dhamija, Advocate for appellant.

                             Mr.Devender Punia, Advocate for the respondent.

                                                   O R D E R

RAM SINGH CHAUDHARY, JUDICIAL MEMBER:

          Delay in filing the appeal is condoned for the reasons stated in the application filed for condonation of delay.

2.      The brief facts of the case are that complainant purchased medi Classic Insurance Policy (Individual), which was valid from 03.09.2013 to 02.09.2014 and premium of Rs.3326/- was paid to the O.P. and complainant insured of Rs.2,00,000/-, all the ailments, illness and bodily injury through accident was covered under the said policy, but not exceeding the sum insured.   He suffered pain in his left knee on  10.11.2013, he contacted the doctor at Jindal Hospital Hisar, on 13.11.2013, the treating doctor prescribed medicines, but, the condition of the complainant  was  deteriorated.  He was advised X-ray and MRI and problem was diagnosed to be ACL Tear Left Knee and on the advice of Dr. Amit Bhutani, he had underwent surgery.  He admitted in the hospital on 24.02.2014 and operated upon on 27.02.2014. The complainant was discharged on 01.03.2014. Intimation with regard to the claim was submitted to the insurance company and submitted all the relevant bills, but, O.P. repudiated the claim of the complainant on 28.03.2014 on the ground that as per exclusion No.1 of the policy, the company is not liable to make the payment in respect of the expenses for treatment of the pre-existing diseases until 48 months of continuous coverage has elapsed, since inception of the first policy with the company.  Thus there was deficiency in service on the part of the O.P.

3.      O.P. filed  reply controverting his averments.  O.P alleged that complainant was admitted in NC Jindal Hospital on 18.02.2014.  The complainant obtained the treatment of Anterior Cruciate Ligament (
ACL Tear Left Knee). The complainant purchased the medi-claim policy to treatment of his old pain and knee replacement. All the allegations were denied and requested to dismiss the complaint.

4.      After hearing both the parties, District Consumer Disputes Redressal Forum, Hisar (In short “District Forum”) allowed the complaint and  directed the O.P. to pay the amount of Rs.1,00,000/- with interest @ 9% p.a. from the date of filing the present complaint i.e. 19.02.2015 till  payment. Complainant is also hereby awarded compensation of Rs.5000/- for his harassment and mental agony and Rs.1000/- as litigation expenses etc.

5.      Feeling aggrieved therefrom, O.P-appellant has preferred this appeal.

6.      This argument have been advanced by Sh.Satpal Dhamija, the learned counsel for the appellant as well as Sh.Devender Punia, the learned counsel for the respondent. With their kind assistance the entire records as well as the original record of the District Forum including whatever the evidence has been led on behalf of  both the parties had also been properly perused and examined.

7.      As far as the issuing of policy is concerned, it is not in dispute.  However,  the dispute arises as immediately after obtaining the insurance policy, the complainant was treated for tear of ACL in inter condylar notch with poor visualization of femoral attachment, tear in posterior horn of medical meniscus and Mild joint effusion as has been mentioned in the document Annexure P-4 and it is considered to be a conservative and cooperative treatment of joint diseases (other than caused by accident). Similarly in the exclusion clause No.3 which deals with the fact that during the first two years of continuous operation of insurance cover, the sub para No.d the conservative and operative treatment of joint diseases ( other than caused by accident)  as well as sub para No.e, all types of joint replacement (other than caused by accident) covers the cause of the complainant and such a kind of serious disease cannot occur  all of sudden unless and until you have the back history or pre-existing disease. Though, the complainant may be under treatment of pre-existing disease but as per the treatment and the  diagnosed or the impression obtained in report Annexure P-4, which could be safely observed that since it is a case of tear of ACL in inter condylar notch with poor visualization of femoral attachment, tear in posterior horn of medical meniscus and Mild joint effusion, it would be considered to be a pre-existing disease. The insurance company is not liable to make the payment. Since, it was not disclosed by the complainant in the proposal form, the complainant cannot take the benefit from the same for the purpose of claiming any medical claim.

8.      Hence with the above observation and discussion, the learned District forum committed a grave error by allowing the complaint and the order as such is not legally sustainable and while accepting the appeal, the impugned order dated 30.03.2017 stands set aside for all intents and purposes and the complaint accordingly stands dismissed.

9.      The statutory amount of Rs.25,000/- deposited at the time of filing the appeal be refunded to the appellant against proper receipt and identification in accordance with rules, after the expiry of period of appeal/revision, if any.

 

January 23rd, 2019     Manjula               Ram Singh Chaudhary,                                              Member               Judicial Member                                                          Addl. Bench          Addl.Bench                 

S.K.