SHANO WADHAWAN vs National Insurance Company Ltd.

THE present appeal has been filed assailing the order of District Forum-VI, Kasturba Gandhi Marg, New Delhi dated 1.6.1999, passed in Complaint Case No. 515/97 entitled Ms. Shano Wadhawan v. National Insurance Company Limited.

THE relevant facts, in brief, are that the appellant had filed a complaint under Section 12 of the Consumer Protection Act, 1986 (hereinafter referred to as the ''Act''), before the District Forum with the grievance that the respondent had wrongly repudiated the mediclaim of the appellant on the ground that the disease for which the treatment was taken by the appellant was pre-existing disease. The appellant was a joint holder of 1000 units of the GIC Growth Plus II Scheme of the respondent having the Face Value of Rs. 10,000/-. In terms of the said scheme, the appellant was entitled to Medical Insurance Cover for the reimbursement of pre-hospitalization and post-hospitalization expenses to the extent of 3 times the amount of investment per annum subject to an upper limit of Rs. 1,50,000/-. The appellant was admitted in Holy Family Hospital, New Delhi for the treatment of acute pain and swelling in the knee joint of both the legs on 13.3.1996 and was discharged on 16.3.1996. Thereafter, the appellant submitted her claim for the reimbursement of the expenses incurred in respect of the hospitalization and treatment incurred, i.e. Rs. 5,294.95. However, the said claim of the appellant was repudiated on the ground that the disease for which the treatment was undertaken by the appellant was pre-existing. The appellant, therefore, filed a complaint before the District Forum praying for directions to the respondent to reimburse the amount of Rs. 5,294.95 together with interest @ 18% p.a. w.e.f. 26.3.1996 alongwith compensation and costs.

The respondent in its reply/written version filed before the District Forum took the defence that the claim of the appellant had been repudiated on the basis of the opinion of Dr. Vijay Kumar Arora, a Panel Doctor of the respondent Insurance Company, who had observed that the appellant had been suffering from the disease in question, before the inception of the policy, i.e., 2.4.1994 and as such the claim of the appellant was a no claim in terms of the policy. Therefore, there being no deficiency in service on its part, the complaint of the appellant was liable to be dismissed with costs.

THE learned District Forum on the basis of material before it dismissed the complaint of the appellant on the ground that the disease for which the treatment was taken by the appellant being pre-existing at the inception of the insurance cover, the claim of the appellant, was rightly repudiated by the appellant Insurance Company and did not amount to deficiency in service. Aggrieved by the aforesaid impugned order, the appellant has approached this Commission by filing the present appeal.

WE have carefully perused the documents/material on record, as well as, have heard the parties at length. The sole controversy involved in the present appeal is as to whether the disease for which the appellant was hospitalized and had incurred expenditure was pre-existing prior to the inception of the Insurance Cover, and as such a claim for the same was not maintainable in terms of the scheme of the respondent. The learned District Forum has dismissed the complaint of the appellant on the ground that in view of the evidence placed on record the appellant was suffering from disease, for which the claim has been preferred prior to the inception of the mediclaim cover. However, on going through the material on record, it is noticed by us that in the complaint it is specifically mentioned that the appellant was hospitalized for treatment of swelling and pain in knee joints. Whereas according to the case summary and discharge records dated 16.7.1996, the appellant was suffering from pain and heaviness in the neck, full back and lower limbs off and on since long time and suffering from Scoliosis since 4 years but pain and swelling in knees only since last 4-5 months. The mediclaim cover became operational as on 2.4.1994. Therefore, the ailment of knee joint, swelling and pain for which the appellant underwent treatment can not be termed as pre-existing. Even the affidavit of Dr. Vijay Kumar Arora, placed on record and on the basis of which the Insurance Company had concluded that the claim of the appellant was no claim, specifically states that on account of non-availability of the X-ray and other relevant documents, he was not in a position to arrive at a correct finding. In this regard, it would be pertinent to point out that the respondent could have carried out the investigations and X-rays, in order to ascertain the fact as to whether the disease for which the appellant had been treated in the hospital and for which the reimbursement has been claimed was indeed pre-existing or not. The opinion of the Panel Doctor, Dr. Vijay Kumar Arora of the Insurance Company being in conclusive in the absence of X-ray and other documents, it was not appropriate on the part of the respondent Company to repudiate the claim of the appellant on the basis of conjectures and surmises, in the absence of any authenticated diagnosis of a doctor. As such the appeal filed by the appellant deserves to be allowed. In consequence, the impugned order of the learned District Forum is set aside and the present appeal is allowed with the directions to the respondent to pay to the appellant a sum of Rs. 5,294.95 together with interest @ 12% p.a. w.e.f. 3 months after the date of the presentation of the claim by the appellant, up to the date of actual payment. The appellant is also entitled to the cost of proceedings. The same are fixed at Rs. 2,000/-. The amounts in terms of the present order are to be paid by the respondent within 30 days of the receipt of the order. The present appeal stands disposed of in above terms. Appeal disposed of.