DISTRICT CONSUMER DISPUTES REDRESSAL FORUM  (CENTRAL)

MAHARANA PARTAP BUS TERMINAL: 5^th  FLOOR.

KASHMERE GATE DELHI.

No. DF / Central/ 2015

Satish Kumar

S/o Late Gauri Shankar,

R/o C-1, Akriti Apartment,

Opposite Water Tank, Gandhi Nagar, Ghaziabad, UP                                                       

..........Complainant

Versus

1. M. D. India Health Care Ltd

WEA Ground Floor,

Ganga Plaza, Karol Bagh, New Delhi

2. Oriental Insurance Co. Ltd

Ambedkar Road, Ghaziabad, UP

                                 ..........Respondent/OP

BEFORE

SH. RAKESH KAPOOR, PRESIDENT

SH. S. N. SHUKLA, MEMBER

ORDER

Per Sh. RakeshKapoor, President 

 The complainant had taken up a happy family floater policy from  OP2  which   covered all the family member of the complainant . It is alleged by the complainant that his wife Smt. Deepa Sharma was admitted in a hospital in a under the supervisor of Dr. Keshav Das Sadhwani a nephrologist for kidney problems and had expired on 13.11.2012.  The complainant had lodged a claim with the OP in respect of the expenses incurred on her treatment which was repudiated by OP2.  Hence, the complaint.

      OP2  has contested the complaint and has  filed a written statement. It has claimed that the complaint is false and frivolous it has admit admitted that the complainant has purchased the happy family floater  policy from it. It has also admitted that the above policy was a continuing on and was in a third consecutive year. It has not denied that the wife of the complainant was admitted in a hospital  and had expired  die to kidney problem.  It has claimed that it has found it to be not payable  as per exclusion clause no. 4.1 of the  insurance purchased by the complainant.  It has, therefore, justified its  action of repudiation of the claim and has prayed that the complaint be dismissed.

    We have heard arguments advanced at the bar and have perused the record.

   The sole question for our consideration is as to whether the claim of the complainant has been rightly repudiated  by the  Ops .  The Ops have taken refuge behind clause 4.1 of  the policy of insurance purchased by the complainant  clause  4.1 relates to pre-existing  health condition or disease or ailment/ injuries. It reads as under:-
 

4.1Pre-existing health condition or disease or ailment / injuries:

Any ailment / disease / injuries / health condition which are pre-existing (treated / untreated, declared / not declared in the proposal form), when the cover incepts for the first time are excluded upto 4 years of this policy being in force continuously.

For the purpose of applying this condition, the date of inception of this Mediclaim policy taken shall be considered, provided the renewals have been continuous and without any break in period.
This exclusion will also apply to any complications arising from pre existing ailments / diseases / injuries. Such complications will be considered as a part of the pre-existing health condition or disease. To illustrate if a person is suffering from hypertension or diabetes or both hypertension and diabetes at the time of taking the policy, then policy shall be subject to following exclusions.

   A perusal of the aforesaid clause makes it amply clear that expenses on any ailment/ disease which are pre-existing at the time of the initiation of the policy have to be excluded up to a period four years. Since, the policy purchased by the complainant had not completed four years and since the wife of the complainant had suffered from hypertensive nephropathy, in our considered opinion OP2 was justified in repudiating the claim lodged by the complainant. We, therefore, see no merits in this complaint. The same is hereby dismissed.

          Copy of the order be made available to the parties as per rule.  File be consigned to record room.

Announced on.....................

(S N SHUKLA)                        (RAKESH KAPOOR)

     MEMBER                              PRESIDENT