IMPORTANT POINT
Mediclaim cannot be arbitrarily rejected on the ground of pre-existing disease

S.R. Khanzode, Judicial Member—This appeal takes an exception to an order dated 28/07/2010 passed in consumer complaint No.271/2007; Smt. Jayashree Subhash Swadi v. The New India Assurance Co. Ltd., passed by the South Mumbai District Consumer Disputes Redressal Forum (hereinafter referred as ‘forum’ for brevity).

2. It is a case of repudiation of the medi-claim on the ground of pre-existing disease. The forum overruled the contention of the Insurance Company and awarded the claim as confined to the actual medical expenses and disallowing the claim for expenses of taxi. Point of limitation was also raised but the forum held that the consumer complaint was not barred by limitation. Feeling aggrieved thereby, opponent /Insurance company (herein after referred as ‘Insurance company’) filed this appeal.

3. Heard both the sides.

4. In the instance case holding the reference date as final repudiation of the insurance claim, the forum held that the consumer complaint is not barred by limitation and, hence the application for condonation of delay, stood disposed of accordingly. However, forum erred in holding date of repudiation as a starting point of limitation in view of the observations of the Apex Court in the case of Kandimalla Raghavaiah & Co. v. National Insurance Co. Ltd., III (2009) CPJ 75 (SC).

5. The starting point of limitation is the date of treatment received by the complainant. Complainant has already filed an application for condonation of delay before the forum narrating as to how after repudiation of the insurance claim at the first -instance on 16.2.2005 and, thereafter, as per the advice received from the officials of the Insurance company, complainant preferred an appeal/representation against the said rejection to the Divisional Manager, who forwarded the said representation to the Grievance cell on 9.5.2005 and, thereafter communicated final rejection on 26.7.2006. Complainant also thereafter referred the matter to the Ombudsman but in vain and, ultimately, filed this consumer complaint on 27.9.2007. Thus, from the statement given it could be seen that after rejection of the insurance claim on 16.2.2005, respondent/original complainant (hereinafter referred as ‘complainant’) on advice of the officials of the Insurance company itself made representation to the Divisional Manager, who in turn sent the same to the Grievance Cell and, thereafter, the complainant bonafidely prosecuted the matter with the Ombudsman and only after such remedy got exhausted, she preferred this consumer complaint. Until the decision of Kandimalla’s case, everybody was under impression that starting point of limitation is the date of repudiation.

6. Under the circumstances, we find that the complainant has satisfactorily explained the delay and the delay which occurred in filing consumer complaint deserves to be condoned. Therefore, we affirm the finding as far as limitation is concerned holding that since delay is satisfactorily explained, consumer complaint is not barred by limitation.

7. Coming to the ground of repudiation, on the ground of pre-existing disease, the Insurance company miserably failed to justify their such repudiation. They tried to rely upon one opinion obtained from one Oncologist but same is not tendered in evidence. Besides that complainant has filed the treating doctor’s opinion showing that it was not a pre-existing disease. It is pertinent to note that only after getting examined for the lump observed, it was detected that the complainant was suffering from Breast Cancer. Therefore, the forum rightly held that the Insurance Company miserably failed to justify their repudiation. Hence, the repudiation being arbitrary, there is deficiency in service on the part of Insurance company and the insurance claim is rightly, therefore, awarded by the forum. We hold accordingly. Thus, finding the appeal devoid of any substance, we pass the following order.

Appeal dismissed.

ORDER

Appeal stands dismissed.

Parties to bear