IMPORTANT POINT
If joint replacement became necessary on account of injury, it would not be case of joint replacement due to degenerative condition.

V.K. Jain, Presiding Member—The complainants/respondents obtained a mediclaim policy from the petitioner company, for the period from 16.1.2008 to 15.1.2009 and then from 16.1.2009 to 15.1.2010 for a sum assured of Rs.3 lakhs. Earlier to that, the complainants had obtained a mediclaim policy for the period from 24.12.2004 to 23.12.2005 and 16.11.2006 to 15.11.2007. The complainant No.2 Mrs. Om Kumari Bohra having sustained a fracture during the subsistence of the first policy taken by her, the expenses incurred by her were reimbursed by the insurer. Later, she was advised replacement of right hip joint and, therefore, she remained admitted as an indoor patient in Sant Parmanand Hospital, Delhi from 27.4.2009 to 9.5.2009 and incurred an expenditure of Rs.2,88,000/- on the said replacement. A claim was then lodged by her for reimbursement of the aforesaid expenditure incurred at Sant Parmanand Hospital, Delhi but the claim was rejected primarily on the ground that there was a break in the insurance policy and the claim was excluded under clause 4.1 of the Exclusion Clause contained in the policy and the aforesaid disease was concealed by her while obtaining the policy for the period 16.1.2009 to 15.1.2010. Being aggrieved, the complainant approached the concerned District Forum by way a consumer complaint.

2. The complaint was resisted by the insurer primarily on the ground that the replacement of hip bone was a continuation of the fracture which the complainant had sustained in the year 2005 and, therefore, the claim was inadmissible in terms of the Exclusion Clause 4.1. of the insurance policy.

3. The District Forum vide order dated 7.10.2013 allowed the complaint and directed the insurer to pay a sum of Rs.2,88,000/- to the complainants along with interest @ 9% p.a., compensation quantified at Rs.10,000/- and the cost of ligation quantified at Rs.3,000/-.

4. Being aggrieved from the order passed by the District Forum, insurer approached the concerned State Commission by way an appeal. The said appeal having been dismissed with cost assessed at Rs.20,000/-, the insurer is before this Commission by way of this revision petition.

5. Clause 4.1. of the terms and conditions applicable to the mediclaim policy taken by the complainant reads as under:-

“4.1 Pre-existing disease/condition: All diseases/injuries/conditions, which are pre-existing when the cover incepts for the first time (except as shown hereunder). Any complication arising from pre-existing disease/ailment/injury will be considered as a part of pre-existing condition. This exclusion will be deleted after four consecutive claim free policy years provided there was no hospitalisation for the pre-existing disease/ailment/condition/injury during the said four years of insurance policy with our Company.”

Clause 4.3 of the said policy reads as under:-

“4.3 Waiting period for specified disease / ailments / conditions:

From the time of inception of the cover, the policy will not cover the following diseases/ailments/conditions for the duration shown below. This exclusion will be deleted after the duration shown, provided the policy has been continuously renewed with our Company without any break.

Sr. No.	Name of Disease/Ailment/Surgery not covered for	Duration
22	Joint Replacement due to Degenerative Condition	Four years”

6. The Discharge Summary issued to complainant Mrs. Om Kumari Bohra by Delhi Institute of Trauma and Orthopaedics Sant Parmanand Hospital, Delhi to the extent it is relevant, reads as under:-

“Diagnosis: Non-union Right S/T Fracture with Recon Nail (Zimmer) & LCP in Situ

Operation : Implant Removal + THR (36 mm LDH-MOP – Zimmer) + Bone Grafting

Summary : Patient presented with history of fracture subtrochanteric right femur after a fall at home. She was treated by DHS fixation in Jan 2005, post-op period was uneventful.