The District Consumer Disputes Redressal Forum has directed an insurance company to pay Rs 2,16,454 as medical insurance claim along with Rs 10,000 as compensation and Rs 2,000 as litigation expenses to a local resident, whose claim was repudiated by it.
Earlier, Raman Kumar Mehta, a resident of Katra Khazana, had filed a complaint against National Insurance Company stating that he was subscriber of Mediclaim Policy issued by the opposite party from 2012 onwards.
He said during the insurance cover he had heart problem for which he was admitted to a hospital. He stated that he spent Rs 2,16,454 on treatment for which claim was lodged with the opposite party.
His claim was repudiated citing the reason that he was a known case of the disease since 2003, he added. He admitted that he had faced the problem, but was completely cured with angioplasty.
He stated that the problem which he faced in 2014 was a fresh lesion and had got no correlation with the cardiac condition or treatment received in 2003.
The opposite party in its reply stated that the claim was rightly repudiated as the complainant had a history of the disease.
The company stated that as per the new insurance policy, the complainant was entitled to medical reimbursement regarding pre-existing disease, including heart ailment, after the expiry of three years from the inception of the insurance policy.
It stated that the policy in dispute was taken on January 17, 2012, and the requisite three years period did not expire on November 6, 2014.
The forum took notice of a condition in the policy papers that stated: Pre-existing disease shall mean any condition, ailment or injury or related condition(s) for which you have signs or symptoms and/or were diagnosed and/or received medical advice/treatment within 48 months prior to your first policy with us.The forum stated: This document belongs to the Bank of India, which has issued the policy.
The opposite party has not challenged or denied the genuineness of the document.The forum said it was the case of the complainant, who had got CAD treatment in 2003.
He was fully cured after getting the treatment. The second treatment, which was disputed, was obtained in 2014 only after a gap of 11 years.
The forum stated that in the light of the said condition, the complainant’s condition could not be termed as pre-existing disease and hence condition of three years applied by the opposite party to deny the claim was not applicable in this case.