State Consumer Disputes Redressal Commission
Nic Ltd. vs Pankaj Jain on 18 March, 2015
Daily Order STATE CONSUMER DISPUTES REDRESSAL COMMISSION : DELHI (Constituted under Section 9 of the Consumer Protection Act, 1986) Date of Decision: 18.3.2015 First Appeal No. 751/2012 National Insurance Co. Ltd. Delhi Regional Office - II 2E/9, Jhandewalan Extension New Delhi-110055 Vs. Pankaj Jain R/o D-154, Phase-I Vivek Vihar, Delhi-110095 .......Respondent CORAM N P Kaushik Member (Judicial), Salma Noor Member
1. Whether reporters of local newspaper be allowed to see the judgment?- Yes
2. To be referred to the reporter or not? - Yes N P Kaushik Member (Judicial) The appellant has impugned the order dated 10.7.2012 passed by the District Forum (Central), Kashmere Gate. Vide this order the Ld. District Forum has allowed the complaint The appellant has been directed to pay to the complainant an amount of Rs.20,000/- towards compensation. Litigation charges of Rs.5,000/- were also awarded.
In brief, the complainant had taken a Parivar Mediclaim Policy in favour of his father, Sh. Narender Jain and mother, Smt. Shashi Jain for a sum of Rs.2,50,000/- from National Insurance Co. Ltd. (in short, 'the OP'). Mother of the complainant got treatment of replacement of knees from Deepak Memorial Hospital, 5, Institutional Area, Vikas Marg, Extension-II, Delhi-110 092. An amount of Rs.1,15,000/- was paid to the hospital. Another amount of Rs.1,90,000/- was spent on implants. Upon preference of the claim, it was repudiated by the OP citing clauses 4.1, 4.2 and 4.3 of the policy. Contention of the OP was that during the first two years of the operation of the policy, the expenses incurred on joint replacement were not admissible. Ld. District Forum observed that the OP had wrongly relied upon clause 4.3 of the policy.
Clauses 4.1, 4.2 and 4.3 of the policy which are relied in the preset context are reproduced below:
"4.1 All diseases/injuries which are pre existing when the cover incepts for the first time. However, those diseases will be covered after four continuous claim free policy years. For the purpose of applying this condition, the period of cover under Mediclaim policy taken from National Insurance Company only will be considered.
Preexisting disease like Diabetes and Hypertension will be covered from the inception of the policy on payment of additional premium by the insured.
Any disease other than those stated in clause 4.3 contracted by the insured person during the first 30 days from the commencement date of the policy. This condition 4.2 shall not however, apply in case of the insured person having been covered under this scheme or group insurance scheme with any of the Indian Insurance Companies for a continuous period of preceding 12 months without any break.
During the first two years of the operation of insurance cover, the expenses on the treatment of diseases such as Cataract, Benign Prostatic Hypertrophy, Hysterectomy, hermia, Hysrocoele, Internal Congenital Defects/Diseases or Anomalies, Fistula in Anus, Piles, Chronic Fissure in Anus. Pilonidal congenital Defects/Diseases or Anomalies. Fistula in Anus, Pilies Chronic Fissure in Anus, Pilonidal Sinus. Sinusitis Stone disease of any size, Benign Lumps/ growths in any part of the body, CSOM (Chronic Suppurative Otitis Media) Joint replacement of any kind unless arising out of accident, Surgical treatment of Tonsils & Adenoids. Deviated Nasal Septum and Chronic Diseases are not payable, if these diseases are pre-existing at the time of proposal, they will not be covered even during subsequent period of renewal too."
Admittedly the parents of the complainant were the beneficiaries of the Mediclaim policy for the period from 8.11.2007 to 7.11.2008. Likewise they are covered in other policy for the period from 87.11.2008 to 7.11.2009 and thereafter from 8.11.2009 to 7.11.2010. In other words they have been enjoying continuously the Mediclaim policy for a period of two years prior to the treatment in question.
We are, therefore, of the considered opinion that the trial court has rightly allowed the complaint. The order dated 10.7.2012 passed by the District Forum do not warrant any interference.
Appeal is accordingly dismissed.
File be consigned to Record Room.
(N P Kaushik) Member (Judicial) (Salma Noor) Member ak