IMPORTANT POINT
Existence of Disease – There is no reason for the insurance company to connect the existence of diabetes with the disease for which treatment has been taken.

ORDER

A.C. Raval, Presiding Member—The appellants – original respondents have filed this appeal under section 15 of the consumer protection Act being aggrieved by and dissatisfied with the order dated 07.10.2015 passed by the learned District Consumer Disputes Redressal Forum, Ahmedabad City (hereinafter referred to as “learned District Forum”) in Consumer Complaint No.13 of 2015.

2. Heard learned advocate Mr. N.M. Shinroja for the appellants – original respondents and also heard learned advocate Mr. R.U. Nahar for the opponents – original complainant.

Facts of the case:

3. It is the case of the complainant that complainant no.2, who is the father of complainant no.1, has taken the mediclaim policy from the Oriental Insurance Company on 14.11.2005. It is continuously renewed till 2008-09 without any break. Thereafter, complainant no.1 became major and policy was taken in his name for the period from 14.11.2009 to 13.11.2010 insured with United India Insurance Company Ltd. In the said policy, renewal number is mentioned of the previous insurance company’s policy. Thereafter, policy was renewed with the Oriental Insurance Company Ltd., for the period from 14.11.2010 to 19.11.2011. The same was again renewed for the period from 29.11.2012 to 28.11.2013 and the sum insured was Rs.3,00,000/- in the Silver Plan.

4. The complainant no.2 had a chest pain and admitted in Sterling Hospital, Ahmedabad, on 21.10.2013, when he was diagnosed with Anterior Wall Myocardial Infarction with LTRI and Diabetes Mellitus and thereafter, Coronary Angiography / Angioplasty was done on 21.10.2013. The patient was discharged on 29.10.2013. The total expenses incurred by the complainant was Rs.5,38,570/-. The complainant has given intimation to the opponents and by providing the necessary papers, the claim was lodged on 31.10.2013. The sum insured in the policy was less than the expenses incurred for the treatment, hence, the complainants have restricted their claim for Rs.3,00,000/-. The insurance company did not take any decision for 10 months after lodging of the claim. The complainant approached the insurance company by email that after almost 10 months, complainant received pre-repudiation statement from opponent no.2 TPA. The pre-repudiation statement dated 13.08.2014 was received by the complainant where it is mentioned that pre-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. It is further stated that as per the policy terms and conditions, the claim is not payable under Clause No.4.1. Final repudiation letter was issued on 28.08.2014. The grounds stated in the repudiation letter was that the policy is covered with Oriental Insurance Company since 3 years but the insured is suffering from Non-ST elevation (NSTEMI) Myocardial Infarction since 6 years as per doctor’s consultation, hence, the claim is not payable and the company stands no liability against the claim. Being aggrieved with the repudiation by the insurance company, the complainant preferred Consumer Complaint No.13 of 2015 before the Ld. District Forum, Ahmedabad City (Main). The Ld. District Forum was pleased to allow the complaint vide order dated 07.10.2017. Hence, being aggrieved by and dissatisfied with the order passed by the Ld. District Forum, the opponent Insurance Company has preferred the present appeal.

Arguments of the Appellants:

5. The appellant – original opponent Insurance Company has filed the written arguments in this appeal. As per the written submissions, the claim of the complainant no.2 has been rightly and legally repudiated by the Insurance Company. That the complainant no.2 was admitted for the treatment of Anterior Wall Myocardial Infarction with Diabetes Mellitus with Coronary Artery disease with S/P PTCA