IMPORTANT POINT
Claim can be repudiated on the basis of exclusion clause.

Dr. S.M. Kantikar, Member—This revision petition is filed under Section 21(b) of the Consumer Protection Act, 1986 against the order dated 04.10.2012 passed in First Appeal No. 413 of 2012 by Haryana State Consumer Disputes Redressal Commission, Panchkula (in short, ‘the State Commission’) whereby the State Commission accepted the appeal and set aside the order dated 9.2.2012 passed by District Consumer Disputes Redressal Forum, Sonepat (in short, ‘the State Commission’).

2. The brief facts of the case are that the complainant was a Medi-claim policy holder since 25.4.2007 and regularly renewed upto period from 25.04.2009 to 24.04.2010. The sum assured was of Rs 3,30,000/- including Rs 30,000/- as Bonus amount. On 04.12.2009, the complainant visited Medanta Hospital and consulted Dr. Rajagopala for her complaints of pain in both the knees. On 17.12.2009, the complainant underwent Arthroplasty of both the knees. The complainant paid a sum of Rs 3,75,170/- for the treatment. After discharge, the complainant approached the OP for reimbursement of medical expenditure through Medi-claim policy. But OP repudiated the claim of the complainant on 23.12.2010 stating that as per exclusion clause 4.1 of the policy, the complainant had pre-existing disease. Therefore, against the alleged illegal repudiation, the complainant filed complaint before the District Consumer Redressal Forum, Sonipat. (herein after referred as District Forum).

3. The OP contested the complaint by filing written version. The OP denied that the patient was not having any joint pain at the time of purchase of policy on 25.4.2007, also denied that the complainant started knee joint problems in the month of June, 2009. As per the treatment record of Medanta Hospital, the complainant consulted Dr. Rajgopala, who after clinical examination and certain laboratory tests, diagnosed her as suffering from both knee joint pain. As per prescription slip and the X-ray report done in the year 2004, it was mentioned about ‘Advanced Degenerative Disease’. Therefore, it was clear that the patient was suffering from knee pains since year 2004 i.e. prior to the insurance coverage. The claim was repudiated after taking the opinion from Company’s doctor. As per condition 4.1-Pre-existing disease of the policy, the claim of complainant was not payable, as she was having pre-existing disease in her both knees i.e. much prior to 2007.

4. Considering the pleadings and evidence, the District Forum vide order dated 09.02.2011allowed the complaint and directed the OP to pay an amount of Rs 3,00,000/- to the complainant along with interest @ 9% per annum from the date of filling of the complaint and also awarded Rs 1,000/- for mental agony and litigation expenses.

5. Being aggrieved by the order of District Forum, the complainant approached the State Commission by way of first Appeal. The Appeal was allowed vide order dated 4.10.2012 and consequently, the complaint was dismissed. The State Commission held that the Medi-claim policy was purchased by complainant in the year 2007 whereas the complainant has undergone knee replacement in the year 2009 i.e. within three years from the date of obtaining the policy. Therefore, under condition No. 4.3, serial no. 22 of the terms and conditions of the policy, the complainant was not entitled for Medi-claim benefits under the policy.

6. Aggrieved by the impugned order of State Commission, the complainant filed revision petition.

7. As per the treatment of Medanta Hospital certain tests were suggested to the Complainant and it was found that the complainant was suffering from knee joints pain and the x-ray report of the complainant of the year 2004 showed advance disease and the same is also found mentioned in the prescription issued by the said doctor on 4.12.2009 meaning thereby the complainant was suffering from knee pain since year 2004 i.e. much prior to her insurance policy which was started in the year 2007.

8. We have heard the learned counsel for