IMPORTANT POINT
Waiting period – Since the waiting period of 48 months had not elapsed after the sum insured was enhanced by the complainant under the subject policy, the concerned claim has rightly been denied by the Insurance Company.

ORDER

Dr. Monika Malik, Member—This appeal by the complainant/appellant (hereinafter referred to as ‘complainant), is directed against the order dated 10.8.2017, passed by the District Consumer Disputes Redressal Commission, Ratlam (for short ‘District Commission’), in complaint case No. 18/2017, whereby the District Commission has dismissed the complaint filed by the complainant.

2. Briefly put, facts of the case are that the complainant is insured with opposite parties-the Oriental Insurance Company Ltd. (hereinafter referred as ‘Insurance Company’) via mediclaim policy. Earlier the sum insured under the policy was Rs.50,000/- and that was for the period from 10.6.2009 to 10.6.2011. Thereafter risk coverage was enhanced to Rs.1,50,000/- , w.e.f. 26.9.2011 to 26.9.2013. Thereafter, from 26.9.2013 onwards the risk coverage was further enhanced to Rs.2 lacs. The subject policy was valid till 26.9.2014, regarding which premium of Rs.5,510/- was paid by the complainant. It is further submitted that the complainant became unwell and was admitted in CHL Appollo Hospital, Indore on 25.6.2014, where angiography was done and subsequently bypass surgery was performed. The complainant was finally discharged from the hospital on 2.7.2014. The complainant incurred expenses of Rs.1,88,821/- in his entire course of treatment. When the complainant approached the Insurance Company regarding payment of the claim amount, he was paid a sum of Rs.50,000/- only against the expenses incurred by him. The complainant alleged that he should have been paid the entire amount of treatment expenses incurred by him and by not doing so, the Insurance Company is deficient in service. Therefore, alleging deficiency in service against the Insurance Company, he approached the District Commission, seeking relief.

3. The Insurance Company resisted the complaint on the ground that the complainant’s claim was not payable as per condition No.4.1 of the policy terms and conditions, whereby a claim is excluded on the basis of treatment of pre-existing aliment. As per discharge summary of the CHL Appollo Hospital, Indore, the complainant was known case of hypertension since the year 1999 and was on regular treatment since the year 2008. The claim was lodged in the year 2013-14 but since the treatment for pre-existing ailment is excluded for a period of 48 months, from the inception of policy cover, his claim was not payable. The complainant was entitled for a sum of Rs. 50,000/- only, which has already been paid to him. The complainant is not entitled to any other relief.

4. The District Commission dismissed the complaint filed by the complainant. Hence this appeal.

5. Heard.

6. Learned counsel for complainant argued that the District Commission has erroneously dismissed the complaint relying on the condition No.4.1 of the policy terms and conditions. The fact is that the complainant was not suffering from any pre-existing ailment and the Insurance Company has failed to prove the same also. The sum insured was enhanced from the year 2011 and the complainant approached the Insurance Company regarding payment of claim amount in the year 2014. Therefore, he is entitled for payment of the entire treatment expenses incurred by him. He thus argued

that the impugned order deserves to be set aside.

7. Learned counsel for the Insurance Company argued that the treatment papers, including the discharge summary available in the record of the District Commission shows that the complainant was a known case of hypertension since the year 1999. The fact is that the complainant had to undergo angiography and subsequently, bypass surgery on account of his prolonged condition of hypertension. Though the sum insured was enhanced to a sum of Rs.2 lacs from the year 2013 onwards but the policy condition regarding pre-existing ailment would apply in the present case. The complainant was entitled for only a sum of Rs.50,000/- which has already been paid. He thus argued that the appeal deserve