State Consumer Disputes Redressal Commission
B.M , The Oriental Insurance Co.Ltd. vs Ashok Kumar Sharma & Ors. on 9 January, 2020
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i{kdkjksa ds vf/koDrk vihykFkhZ dh vksj ls Jh eukst izlkn] vf/koDrkA mRrjoknh dzekad&1 Lor%A mRrjoknh dzekad&2 dh vksj ls Jh /kqzojkt Xoky] vf/koDrkA mRrjoknh dzekad&3 ,di{kh;A // 2 // vkns'k fnukad% 09@01@2020 }kjk%&ekuuh;k Jherh :fp xks;y] lnL;k vihykFkhZ@vukosnd dz-1 uss ;g vihy /kkjk&15 miHkksDrk laj{k.k vf/kfu;e] 1986] ds rgr ftyk miHkksDrk fookn izfrrks"k.k Qksje] nqxZ ¼N-x-½ ¼ftls vkxs laf{kIr esa **ftyk Qksje** lacksf/kr fd;k tk,xk½ ds ifjokn izdj.k dzekad&lhlh@2017@684 v"kksd dqekj "kekZ fo:} "kk[kk izca/kd] fn vksfj;saVy ba";ksjsal daiuh fyfeVsM ,oa vU; nks esa ikfjr vkns"k fnukad&02 vizSy 2019 ftlds }kjk mRrjoknh dz- 1@ifjoknh ds ifjokn dks Lohdkj djrs gq, ;g vknsf'kr fd;k x;k gS fd%& **1- chek daiuh vukosnd dz-1] ifjoknh dks esfMDyse dh jkf"k :Ik;s&1]27]500@&¼,d yk[k lRrkbZl gtkj ikap lkS :Ik;s½ vnk djsA 2- chek daiuh vukosnd dz-1] ifjoknh dks mDr jkf"k ij vkns"k fnukad ls vafre Hkqxrku fnukad rd 09 izfr"kr okf'kZd nj ls C;kt vnk djsA 3- chek daiuh vukosnd dz-1] ifjoknh dks ekufld ijs"kkuh dh {kfriwfrZ ds :Ik esa 40]000@&¼pkyhl gtkj :Ik;s½ vnk djsA 4- vukosnd dz-1] ifjoknh dks okn O;; ds :Ik esa 5]000@&¼ikap gtkj :Ik;s½ Hkh vnk djsA** ls nqf[kr gksdj izLrqr fd;k gSA // 3 // 02- mRrjoknh dz-1@ifjoknh dk ifjokn ftyk Qksje ds le{k laf{kIr esa bl izdkj jgk gS fd mRrjoknh dz-1@ifjoknh viuh ftEesnkjh ds izfr tkx:d jgus ds dkj.k vius rFkk ifjokj ds LokLF; lqj{kk gsrq chek daifu;ksa }kjk esfMDyse dh ikWfylh ysrk jgk gS vkSj blh dze esa fnukad&12-01-2012 ls ;qukbZVsM bafM;k ba";ksjsal daiuh dh ikWfylh fnukad&11-01-2016 rd yxkrkj fy;k FkkA mRrjoknh dz-2@vukosnd dz-2] vihykFkhZ@vukosnd dz-1 dk fodkl vf/kdkjh gS ftlds }kjk mRrjoknh dz-1@ifjoknh ls laidZ fd;k x;k vkSj viuh daiuh ds vkd'kZd vkSj vf/kd ykHk dh tkudkjh mRrjoknh dz-1@ifjoknh dks nh xbZ rFkk ikWfylh ysus dk fuosnu fd;k x;k ftlds fy, vksfj;saVy cSad vkWQ dkWelZ] nqxZ dh "kk[kk esa [kkrk [kksydj mlesa jkf"k tek djus gsrq dgk x;k ftlesa de izhfe;e esa iwjs ifjokj dk 5]00]000@&¼ikap yk[k :Ik;s½ dk esfMDyse doj jgsxkA mRrjoknh dz-1@ifjoknh }kjk mRrjoknh dz-2@vukosnd dz-2 dks viuh iqjkuh ikWfylh vU; daiuh ls gksus dh tkudkjh nh xbZ rks mRrjoknh dz-2@vukosnd dz-2 }kjk mRrjoknh dz- 1@ifjoknh dh ;qukbZVsM bafM;k ba";ksjsal daiuh esa iksVsZfcfyVh ds vk/kkkj ij tkjh djus dh tkudkjh nh xbZ rFkk vk"oLr fd;k fd iksVsZfcfyVh ls iqjkuh ikWfylh ls feyus okys iwjs Qk;ns fn vksfj;saVy ba";ksjsal daiuh dh ikWfylh esa Hkh feysxh vkSj iksVsZfcfyVh ds vk/kkj ij gh fn ;qukbZVsM baf";k ba";ksjsal daiuh dh ikWfylh dks fn vksfj;saVy ba";ksjsal daiuh esa ifjofrZr fd;k x;k vkSj mRrjoknh dz-1@ifjoknh dh pkj lky rd py jgh iwoZ ikWfylh dzekad&270381@48@14@97@00000554 dks // 4 // fnukad&01-12-2015 dks iksVZ dj fn vksfj;saVy ba";ksjsal daiuh fyfeVsM dh ikWfylh dz-&142100@48@2016@2173 tkjh dh xbZ ftldh fe;kn fnukad&12-01-2016 ls 11-01-2017 rd FkhA mRrjoknh dz-1@ifjoknh }kjk vius cM+s HkkbZ ds LokLF; psdvi gsrq Usha Mullapudi Cardiac Centre Hydrabad x;k ftlesa mRrjoknh dz-1@ifjoknh }kjk fnukad&26-02-2016 dks gsYFk psdvi iSdst 5]200@&¼ikap gtkj nks lkS :Ik;s½ esa viuk gsYFk psdvi djk;k ftldk uxn Hkqxrku fd;k x;k ftlesa Vh,eVh ikWftfVo vkus ij MkWDVj }kjk lh,th ¼,aft;ksxzkQh½ gsrq lykg fn;k vkSj fnukad&27-02-2016 dks vLirky esa HkrhZ gksus gsrq funsZ"k fn;kA mRrjoknh dz-1@ifjoknh }kjk fnukad&27-02-2016 dks ,Mfe"ku ds fy, vLirky ds chek foHkkx ls viuh ikWfylh dk dS"kysl VªhVesaV gsrq viuk chek ikWfylh fnukad&26-02-2016 izLrqr fd;k x;k ftlesa vLirky ds chek foHkkx us chek ikWfylh ds vk/kkj ij chek ds TPA dks Request for cashless Hospitalisation for Medical Insurance Policy Hkjdj QSDl fd;k ftlesa lh,th gsrq Sum Total Expected of Hospitalisation 14,000/- Hkstk x;k ysfdu TPA ds }kjk fuosnu dks Lohdkj ugha fd;k x;k rc mRrjoknh dz-1@ifjoknh }kjk mRrjoknh dz-2@vukosnd dz-2 dks eksckbZy ij lwfpr fd;k fd TPA ds }kjk dS"kysl VªhVesaV Lohdkj ugha fd;k tk jgk gSA fnukad&27-02-2016 dks mRrjoknh dz-1@ifjoknh vLirky esa HkrhZ gqvk vkSj dS"kysl VªhVesaV ds fuosnu ds vk/kkj ij fnukad&27-02-2016 dks CAG fd;k x;k vkSj mlesa mUgksaus CAD- LMCA Disease + Double Vessal Disease ik;k x;k vkSj mUgksaus CABG Advice // 5 // fd;k ftlds dkj.k ls mRrjoknh dz-1@ifjoknh dh ekufld ijs"kkkuh c<+ xbZA vLirky ds chek foHkkx }kjk crk;k x;k fd fnukad&26-02- 2016 o 27-02-2016 dks fn vksfj;saVy ba";ksjsal daiuh fyfeVsM ds TPA }kjk dS"kysl esfMDyse Lohdkj ugha fd;k tk jgk gS ftlds dkj.k ubZ chekjh irk pyuk o dS"kysl VªhVesaV u gksus ij mRrjoknh dz- 1@ifjoknh dks Hkkjh ekufld izrkM+uk >syuh iM+hA fnukad&28-02-2016 dks vLirky ds fMLpktZ ds fnu dS"kysl esfMDyse Lohdkj uk gksus ds dkj.k mRrjoknh dz-1@ifjoknh us vius igpku okyksa ls jde dh O;oLFkk dh vkSj vLirky ds 12]276@&¼ckjg gtkj nks lkS fNgRrj :Ik;s½ ds fcy dk Hkqxrku fd;k rFkk 2]360@&¼nks gtkj rhu lkS lkB :Ik;s½ dh nokbZ dz; dh xbZ rFkk baft;ksxzkQh dh lh- Mh- gsrq 1]000@&¼,d gtkj :Ik;s½ fn;kA ubZ chekjh dk irk pyuk o dS"kysl VªhVesaV uk gksus ds dkj.k rFkk iSalksa dh O;oLFkk esa mRrjoknh dz- 1@ifjoknh dks ekufld ijs"kkfu;ksa dk lkeuk djuk iM+kA mRrjoknh dz- 1@ifjoknh gSnkjkckn ds vLirky ls okil vkdj fnukad&02-03-2016 dks lkvksy gkVZ ds;j lsaVj jk;iqj esa uSpqjy ck;ikl ¼EECP½ ,oa ck;ksdsfedy ,aft;ksxzkQh dk VªhVesaV "kq: fd;k ftlds fy, mRrjoknh dz-1@ifjoknh us 1]27]500@&¼,d yk[k lRrkbZl gtkj ikap lkS :Ik;s½ Hkqxrku fd;kA mRrjoknh dz-1@ifjoknh us mRrjoknh dz-2@vukosnd dz-
2 dks leLr tkudkjh nh vkSj mRrjoknh dz-2@vukosnd dz-2 ds funsZ"k ij mRrjoknh dz-3@vukosnd dz-3 dks vkosnu cukdj o leLr Hkqxrku fd;s x;s ewy fcyksa o lkvksy gkVZ ds;j lsaVj ds fcyksa lfgr esfMdy // 6 // jsEclZesaV ds fy, fnukad&01-03-2016 dks Hkstk ftlds ckn Dyse uacj&12439770 tkjh fd;k x;kA ckn esa mRrjoknh dz-1@ifjoknh dks tkudkjh nh xbZ fd mRrjoknh dz-1@ifjoknh dk Dyse jn~n dj fn;k x;k gSA blh nkSjku mRrjoknh dz-1@ifjoknh dh nksuksa iqf=;ksa ds dku o xys ds vkWijs"ku dk nkok Hkqxrku mRrjoknh dz-3@vukosnd dz-3 }kjk fd;k x;kA mRrjoknh dz-1@ifjoknh dks mlds Lo;a ds chek nkok ds fujLr gksus dh lwpuk vihykFkhZ@vukosnd dz-1 ds i= fnukad&13-06- 2016 }kjk nh xbZ ftlesa mUgksaus mRrjoknh dz-1@ifjoknh dk Dyse Pre Existing Disease ds dkj.k jn~n fd;k tkuk crk;kA mRrjoknh dz- 1@ifjoknh }kjk mRrjoknh dz-2 ,oa 3@vukosnd dz-2 ,oa 3 ls laidZ fd;k ftldk dqN ifj.kke ugha fudyus ij mRrjoknh dz-1@ifjoknh us fnukad&06-03-2017 dks vihykFkhZ@vukosnd dz-1 dks fyf[kr esa ;g crk;k fd mls iwoZ esa dksbZ Hkh chekjh ugha Fkh] bldk mfpr dkj.k n"kkZus dh d`ik djsa ;k Dyse dk nkok iznku djus dh d`ik djsaA fnukad&09-03- 2017 dks mRrjoknh dz-3@vukosnd dz-3 us n"kkZ;k fd mudh ikWfylh yxkrkj rhu lky ls ugha gS] ikWfylh ubZ gS bl dkj.k Dyse dk Hkqxrku ugha fd;k tk ldrk gSA rc mRrjoknh dz-1@ifjoknh us fnukad&17-03- 2017 dks vihykFkhZ@vukosnd dz-1 dks iksVZfs cfyVh dh tkudkjh ,oa Dyse jn~n djus ds xyr dkj.k dk Li'Vhdj.k fn;kA fnukad&30-03- 2017 dks vihykFkhZ@vukosnd dz-1 }kjk mRrjoknh dz-1@ifjoknh dks i= }kjk lwfpr fd;k fd vkidh ba";ksjal s esa iksVZfs cfyVh lqfo/kk ugha gSA mRrjoknh dz-1@ifjoknh }kjk fnukad&06-04-2017 dks // 7 // vihykFkhZ@vukosnd dz-1 ds fnukad&30-03-2017 ds i= ds tokc esa dgk fd vkius gels ikWfylh ds lkFk iksVsZfcfyVh D;ksa djk;k vkSj ;fn iksVsZfcfyVh jn~n dh Hkh lwpuk ugha nh xbZ vkSj Dyse ds le; lwfpr dj jgs gSa tks fd xyr gS rFkk blds iwoZ nksuksa iqf=;ksa ds Dyse dk Hkqxrku fd;k x;k gSA mRrjoknh dz-1@ifjoknh }kjk iqu% ikWfylh dk uohuhdj.k fnukad&12-02-2017 ls fnukad&11-01-2018 ds fy, djk;kA bl ikWfylh ds nkSjku mRrjoknh dz-1@ifjoknh }kjk fnukad&18-02-2017 dks ,f"k;u gkVZ baLVhV~;wV eqEcbZ esa viuk gkVZ psdvi djk;k ftlds fy, dS"kysl Dyse 29]000@&¼murhl gtkj :Ik;s½ esa ls 15]645@&¼iUnzg gtkj N% lkS iSarkyhl :Ik;s½ Lohd`r fd;k x;k ,oa 71]005@&¼bdgRrj gtkj ikap :Ik;s½ dk Hkqxrku fd;k x;kA tcfd 01 o'kZ iwoZ 2016 esa m'kk eqYykiqM+h dkfMZ;d lsaVj gSnjkckn ds Dyse dks Pre Existing Disease ,oa iksVsZfcfyVh uk gksus ds dkj.k Dyse dks jn~n dj fn;k vkSj 01 o'kZ ckn mlh chekjh ds bZykt dk Hkqxrku mRrjoknh dz-3@vukosnd dz-3 }kjk fd;k x;k gSA mRrjoknh dz-3@vukosnd dz-3 }kjk Dyse uacj&12439770 dh nkok jkf"k&1]47]336@&¼,d yk[k lSarkyhl gtkj rhu lkS NRrhl :Ik;s½ esa ls 19]823@&¼mUuhl gtkj vkB lkS rsbZl :Ik;s½ dks ,izqo fd;k gS tks vkt fnukad rd vizkIr gS rFkk 1]27]500@&¼,d yk[k lRrkbZl gtkj ikap lkS :Ik;s½ dh EECP o uSpqjy ck;ikl ds fcyksa ds Hkqxrku dks jn~n fd;k gS tks fd lsok esa ?kksj deh dks n"kkZrk gS ftlds dkj.k mRrjoknh dz-1@ifjoknh dks ;g ifjokn ykus dh vko";drk iM+h gSA vr% ifjokn&i= esa of.kZr vuqlkj vuqrks'k fnykbZ tkosA // 8 // 03- vihykFkhZ@vukosnd dz-1 dh vksj ls ftyk Qksje ds le{k fyf[kr dFku izLrqr djrs gq, ;g vfHkopu fd;k x;k gS fd mRrjoknh dz- 2@vukosnd dz-2 us mRrjoknh dz-1@ifjoknh dks iksVsZfcfyVh ds ckjs esa le>k;k FkkA mRrjoknh dz-1@ifjoknh ;qukbZVsM bafM;k ba";ksjsal daiuh ls yh xbZ rRle; dh ekStwnk esfMDyse ikWfylh dks uohuhdj.k }kjk vihykFkhZ@vukosnd dz-1 daiuh esa f"k¶V djuk pkgrk FkkA mRrjoknh dz-1@ifjoknh iksVsZfcfyVh dh "krksZa ls larq'V Fkk vkSj mRrjoknh dz- 1@ifjoknh dks fnukad&12-01-2016 ls fnukad&11-01-2017 dh ekU; vof/k ds fy, vfHkdfFkr ikWfylh tkjh dh FkhA mRrjoknh dz-1@ifjoknh dk 15]936@&¼iUnzg gtkj ukS lkS NRrhl :Ik;s½ dk Dyse lh- ,- th- ¼,aft;ksxzkQh½] nokvksa ,oa lh- ,- th- lhMh [kjhnh ds laca/k esa Fkk ftls mRrjoknh dz-2@vukosnd dz-2 Vhih, us ikWfylh "krZ ds DykWt 4-10 ds rgr chekjh ds vkadyu@y{k.k tkuus ds lac/a k esa gksus ds dkj.k fujLr fd;k gSA mRrjoknh dz-1@ifjoknh }kjk EECP vkSj ck;ksdsfedy ,aft;ksIykLVh ds fy, 1]38]000@&¼,d yk[k vM+rhl gtkj :Ik;s½ dk Dyse fd;k ftls ikus ds fy, mRrjoknh dz-1@ifjoknh ik= ugha gS tks fd mipkj ugha gSA EECP ,d tkap gS] mipkj ugha gSA mRrjoknh dz- 3@vukosnd dz-3 ,d Vh- ih- ,- gS tks vius fo"ks'kK fpfdRldksa dh jk; vkSj lykg ds vk/kkj ij nkos dk fujkdj.k djrk gSA mRrjoknh dz- 1@ifjoknh us vihykFkhZ@vukosnd dz-1 ls ikWfylh fnukad&12-01-2016 dks yh vkSj mlesa lh- ,- Mh- chekjh dk y{k.k fnukad&27-02-2016 dks ikWfylh ds izFke o'kZ esa gh vk;k gS bl dkj.k Dyse Hkqxrku ;ksX; ugha // 9 // gSA iksVZfs cfyVh ds laca/k esa ;g dFku gS fd cSad ba";ksjsal mRikn ¼xzqi esfMDyse ikWfylh½ esa iksVZ Qhpjh ykxw ugha gS ysfdu iksVZfs cfyVh O;fDrxr esfMDyse ikWfylh ds fy, ykxw gS blfy, Dyse Lohdkj ugha fd;k tk ldrk gSA vihykFkhZ@vukosnd dz-1 }kjk mRrjoknh dz- 1@ifjoknh dks fnukad&31-10-2017 dks 19]827@&¼mUuhl gtkj vkB lkS lRrkbZl :Ik;s½ dk nkok jkf"k Hkqxrku fd;k gS] "ks'k jkf"k&1]27]500@&¼,d yk[k lRrkbZl gtkj ikap lkS :Ik;s½ ikWfylh ds vuqlkj ns; ugha gS D;ksafd mDr jkf"k uSpqjy ck;ikl ¼EECP½ ls lacaf/kr gS tks mipkj ugha gSA EECP iz;ksxkRed vkSj tkap ls lacaf/kr gS tks Hkqxrku ;ksX; ugha gSA vihykFkhZ@vukosnd dz-1 }kjk fdlh Hkh izdkj ls lsok esa fuEurk ugha dh xbZ gSA mRrjoknh dz-1@ifjoknh] vihykFkhZ@vukosnd dz-1 ls dksbZ vuqrks'k ikus dk vf/kdkjh ugha gSA vr% vihykFkhZ@vukosnd dz-1 dh vihy Lohdkj dh tkos vkSj ftyk Qksje }kjk ikfjr vkyksP; vkns"k vikLr fd;k tkosA 04- mRrjoknh dz-2 ,oa 3@vukosnd dz-2 ,oa 3 uksfVl rkehyh ds mijkar Hkh ftyk Qksje ds le{k vuqifLFkr Fks vkSj mudh vksj ls dksbZ fyf[kr dFku] "kiFk&i= ,oa nLrkost izLrqr ugha gSA 05- mRrjoknh dz-1@ifjoknh dh vksj ls vius i{k leFkZu esa ftyk Qksje ds le{k Lo;a dk 'kiFk&i= rFkk lwph vuqlkj nLrkost izLrqr fd;k x;k gSA // 10 // 06- vihykFkhZ@vukosnd dz-1 dh vksj ls vius i{k leFkZu esa ftyk Qksje ds le{k jatu dqekj iky dk 'kiFk&i= rFkk lwph vuqlkj nLrkost izLrqr fd;k x;k gSA 07- ftyk Qksje us mRrjoknh dz-1@ifjoknh ds ifjokn dks Lohdkj djrs gq, Åij dafMdk&1 esa of.kZr vuqlkj vuqrks'k iznku fd;k gS ftlds fo:} ;g vihy gSA 08- vihykFkhZ@vukosnd dz-1 dh vksj ls milatkr gksus okys fo}ku vfHkHkk"kd Jh eukst izlkn dk rdZ gS fd ftyk Qksje }kjk vihykFkhZ@vukosnd dz-1 }kjk izLrqr "kiFk&i= ,oa nLrkostksa dk lw{erk ls voyksdu uk dj fof/k fo:} vkns"k ikfjr fd;k gSA ftyk Qksje }kjk ikWfylh dh "krksZa o lqfo/kkvksa dk voyksdu lw{erk ls ughsa fd;k x;k gSA vihykFkhZ@vukosnd dz-1 chek "krksZa ds v/khu dksbZ Hkh jkf"k mRrjoknh dz-1@ifjoknh dks Hkqxrku djus ds fy, nkf;Rok/khu ugha gSA chek viotZu "krZ dzekad&4-1 ds varxZr mRrjoknh dz-1@ifjoknh dk nkok vkrk gS rFkk chek ikWfylh ds vuqlkj yxkrkj rhu o'kZ rd ikWfylh ysus ij nkok ns; gksxkA mRrjoknh dz-1@ifjoknh dks ikWfylh tkjh djus dk ;g izFke o'kZ gS] vr% mRrjoknh dz-1@ifjoknh dk nkok viotZu dh dafMdk&4-1 ds varxZr ns; ugha gSA mRrjoknh dz-1@ifjoknh }kjk uSpqjy ck;ikl EECP ds varxZr 87]500@&¼lrklh gtkj ikap lkS :Ik;s½ dk nkok izLrqr gS tks fd tkap ls lacaf/kr gS blfy, chek "krksZa ds v/khu ns; ugha gSA mRrjoknh dz-1@ifjoknh }kjk bZykt ls lacaf/kr laiw.kZ // 11 // nLrkost izLrqr ugha fd;s x;s gSaA iksVsZfcfyVh O;fDrxr esfMDyse ikWfylh ij ykxw gksrh gSA cSad ba";ksjsal mRikn ¼xzqi esfMDyse ikWfylh½ ij ykxw ugha gksrh gS rFkk EECP lacaf/kr [kpZ Lohdkj ;ksX; ugha gS] D;ksafd [kpsZ mipkj ls lacaf/kr ugha gSa rFkk chek dh "krksZa ds v/khu "ks'k jkf"k&19]827@&¼mUuhl gtkj vkB lkS lRrkbZl :Ik;s½ dk Hkqxrku mRrjoknh dz-1@ifjoknh dks dj fn;k x;k gSA vr% vihykFkhZ@vukosnd dz-1 us mijksDr vk/kkj ij vihy Lohdkj fd;s tkus ,oa ftyk Qksje }kjk ikfjr vkyksP; vkns"k fujLr fd;s tkus dk fuosnu fd;k gSA 09- mRrjoknh dz-1@ifjoknh us fyf[kr rdZ izLrqr dj ;g rdZ fd;k gS fd mRrjoknh dz-1@ifjoknh ,d cSad dehZ gS rFkk vius o vius ifjokj dh LokLF; lqj{kk gsrq lu~ 2012 ls esfMDyse dh ikWfylh ysrk jgk gSA vihykFkhZ@vukosnd dz-1 ds fodkl vf/kdkjh mRrjoknh dz- 2@vukosnd dz-2 us laidZ dj iqjkuh ikWfylh dks iksVZ dj vihykFkhZ@vukosnd dz-1 daiuh dh chek ikWfylh ysus dk vkxzg fd;kA lkFk gh mRrjoknh dz-1@ifjoknh dks de izhfe;e esa T;knk doj dh tkudkjh iznku dh vkSj ;g crk;k fd iqjkuh ikWfylh dh lqfo/kk,a vksfj;saVy cSad vkWQ dkWelZ ds }kjk dh tkus okyh ubZ ikWfylh esa iksVsZfcfyVh ds ek/;e ls feyrh jgsxhA ikWfylh dks iksVZ djkus ds ckn gqbZ LokLF; tkap esa fny dh chekjh dh tkudkjh gqbZ rFkk mlus viuk bZykt djk;k vkSj bZykt esa gq, [kpZ dk Dyse vihykFkhZZ@vukosnd dz-1 daiuh ls fd;k tks Pre existing disease crkdj vLohdkj dj fn;k x;kA // 12 // mRrjoknh dz-1@ifjoknh }kjk iwoZ esa Hkh ,d vU; chek daiuh ;qukbZVsM bafM;k ba";ksjsal daiuh fyfeVsM dh o'kZ 2012&2013 ls yxkrkj esfMDyse ikWfylh yh tk jgh FkhA ;fn Pre existing disease gksrh gS rks mldk nkok iqjkus ikWfylh ls izkIr dj ysrk ysfdu mlds }kjk iwoZ dh ikWfylh ls fdlh izdkj fny ls lacaf/kr chekjh dk dksbZ nkok izkIr ugha fd;k x;k gSA vihykFkhZ@vukosnd dz-1 ,oa mRrjoknh dz-3@vukosnd dz-3 ds }kjk 2016 esa Dyse nkok uacj&121439770 dk Hkqxrku Pre existing disease n"kkZdj nkok jn~n dj fn; x;k Fkk vkSj bl laca/k esa i=kpkj@f"kdk;r djus ij vihykFkhZ@vukosnd dz-1 }kjk 19]823@&¼mUuhl gtkj vkB lkS rsbZl :Ik;s½ dk Hkqxrku dj fn;k x;kA iqu% vkxkeh o'kZ 2017 esa gkVZ ls lacaf/kr psdvi] chekjh ,oa bZykt dk nkok dzekad&14179341 esa ls 82]827@&¼c;klh gtkj vkB lkS lRrkbZl :Ik;s½ esa ls dsoy 71]005@&¼bdgRrj gtkj ikap :Ik;s½ dk Hkqxrku fd;k x;k ftlesa Hkh ,f"k;u gkVZ baLVhV~;wV eqEcbZ esa dS"kysl Dyse Lohd`r djus ds ckn QkbZuy lsVyesaV ds le; ij mls Hkh fujLr dj fn;k x;k rFkk ckn esa jsEclZesaV ds le; 71]005@&¼bdgRrj gtkj ikap :Ik;s½ dk Hkqxrku dj fn;k vkSj mlesa dksbZ ugha n"kkZ;k x;k vkSj uk gh Dyse jn~n fd;k x;kA vihykFkhZ@vukosnd dz-1 }kjk izLrqr "kiFk&i= dh dafMdk&7 ds f}rh; iafDr esa mUgksaus Upto 4 year waiting Period fn;k gS tcfd vihykFkhZ@vukosnd dz-1 }kjk iznRr PNB- Oriental Royal Mediclaim Insurance Policy ds fu;e ,oa "krksZa ds 4-1 dkWye esa 3 Years fy[kk gSA bl izdkj vihykFkhZ@vukosnd dz-1 daiuh Lo;a nks vyx&vyx ckr // 13 // crk jgh gSA vihykFkhZ@vukosnd dz-1 us tku&cw>dj o xyr <ax ls izdj.k dks xqejkg djus ds fy, mRrjoknh dz-1@ifjoknh dks fnukad&09- 11-2017 dks i= fy[kk tks mls fnukad&13-04-2018 dks izkIr gqvk fd vihykFkhZ@vukosnd dz-1 us Dyse dzekad&12439770 esa nkok jkf"k&19]823@&¼mUuhl gtkj vkB lkS rsbZl :Ik;s½ mRrjoknh dz- 3@vukosnd dz-3 us xyr <ax ls Hkqxrku gks x;k gS D;ksafd bl ikWfylh esa iksVZfs cfyVh dh lqfo/kk ugha gS] bl Dyse dh jkf"k dks okil fd;k tkosA Vh- ih- ,- ds }kjk iwoZ esa mls Pre existing disease ls jn~n dj fn;k gS vkSj ckn esa f"kdk;r o tkudkjh iznku djus ij Dyse dk Hkqxrku dj fn;k gS tks fd xyr gSA bl laca/k esa Vh- ih- ,- dh vksj ls mRrjoknh dz-1@ifjoknh dks dksbZ lwpuk o bZ&esy izkIr ugha gqvk FkkA vihykFkhZ@vukosnd dz-1 us iqu% fnukad&18-12-2017 dks fjekbZ.Mj 01 fy[kk tks mRrjoknh dz-1@ifjoknh dks 13-04-2018 dks izkIr gqvk fd Dyse uacj&12439770 dh izkIr nkos jkf"k dks tek dh tkosA bl izdkj vihykFkhZ@vukosnd dz-1 daiuh iqu% nks vyx&vyx ckr dg jgh gS tks mlds lafnX/k ,oa ykijokgh ds vkpkj.k dks mtkxj djrh gSA mRrjoknh dz-1@ifjoknh us vihykFkhZ@vukosnd dz-1 daiuh ds fodkl vf/kdkjh ds funsZ"kkuqlkj iksVsZfcfyVh dk;Z fnukad&01-12-2015 dks izLrqr dj fn;k Fkk vkSj iksVsZfcfyVh dk;Z dk vizqoy ysuk vihykFkhZ@vukosnd dz-1 dh ftEesnkjh FkhA ;fn iksVsZfcfyVh vizqo ugha gqbZ Fkh rks bldh fyf[kr lwpuk mRrjoknh dz-1@ifjoknh dks izkIr ugha gqbZA ;fn mls lwpuk izkIr gks tkrh rks og ;qukbZVsM bafM;k ba";ksjsal daiuh fyfeVsM esa gh viuh // 14 // ikWfylh dks fu;fer j[krkA vihykFkhZ@vukosnd dz-1 chek daiuh us vyx&vyx le; esa vyx&vyx dkj.kksa dks n"kkZ dj mRrjoknh dz- 1@ifjoknh ds tk;t Dyse dks vLohdkj fd;k gS rFkk mRrjoknh dz- 1@ifjoknh dks iqu% ubZ ikWfylh dz-&192100@48@2017@3670 Hkh iznku dh xbZ gS ftlesa iqjkuh ikWfylh dz-&192100@48@20176@2173 dk Hkh mYys[k gS tks vius vki esa nksuksa i{kksa ds vkpj.k dks nf"kZr djrk gSA ftyk Qksje us fo"ks'kK jk; vkSj iksVZsfcfyVh QkeZ ds laca/k esa QkbZafMax esa D;k =qfV dh gS bldk dksbZ mYys[k ugha fd;k gSA vihykFkhZ@vukosnd dz-1 chek daiuh ,d "kkldh; midze gS ftlds dkj.k vke yksx ml ij T;knk Hkjkslk djrs gSaA ,sls esa mRrjoknh dz- 1@ifjoknh ds lkFk bl rjg dk ykijokgh Hkjk d`R; {kek fd, tkus ;ksX; ugha gSA mRrjoknh dz-1@ifjoknh }kjk izLrqr "kiFk&i= fnukad&03-05-2018 dk [k.Mu vihykFkhZ@vukosnd dz-1 }kjk ugha fd;k x;k gS ftldk lw{erk ls v/;;u djus ij ;g Li'V gks tkosxk fd fdl rjg vihykFkhZ@vukosnd dz-1 }kjk mRrjoknh dz-1@ifjoknh dks ijs"kku fd;k x;k gSA ftyk Qksje }kjk ekufld {kfriwfrZ ds ,ot esa ek= 40]000@&¼pkyhl gtkj :Ik;s½ ,oa 5]000@&¼ikap gtkj :Ik;s½ okn O;; fnyk;k x;k gS tks cgqr de gS] vr% mls c<+k;k tkosA mRrjoknh dz-1@ifjoknh dh vksj ls vius rdZ ds leFkZu esa ekuuh; jk'Vªh; vk;ksx }kjk Revision Petition No. 2669/2015 New India Assurance Co. Ltd. Vs. S. S. Kansal, Order Dated-29-10-2015 dk voyacu fy;k gSA // 15 // 10- mRrjoknh dz-2@vukosnd dz-2 dh vksj ls milatkr gksus okys fo}ku vf/koDrk Jh /kqzojkt Xoky us vihykFkhZ@vukosnd dz-1 ds rdZ dk leFkZu djrs gq, vihykFkhZ@vukosnd dz-1 dh vihy Lohdkj fd;s tkus dk fuosnu fd;k gSA 11- mRrjoknh dz-3@vukosnd dz-3 uksfVl rkehyh ds mijkar Hkh vuqifLFkr jgk gS ftlds dkj.k mlds fo:} ,di{kh; dk;Zokgh dh xbZ gSA 12- geus vihykFkhZ@vukosnd dz-1 ,oa mRrjoknh dz-2@vukosnd dz-2 ds fo}ku vfHkHkk"kdx.k rFkk mRrjoknh dz-1@ifjoknh dk rdZ Jo.k fd;k rFkk ftyk Qksje ds vfHkys[k ,oa vkyksP; vkns'k dk Hkh ifj'khyu fd;k x;kA 13- izdj.k ds leqfpr fujkdj.k gsrq fuEu fopkj.kh; iz'u mn~Hkwr gksrs gSa %& ¼1½ D;k vukosndx.k }kjk lsok esa deh dh xbZ gS\ ¼2½ D;k mRrjoknh dz-1@ifjoknh okafNr vuqrks"k ikus dk vf/kdkjh gS\ ;fn gka rks fdl lhek rd\ 14- mRrjoknh dz-1@ifjoknh }kjk ;g rdZ fn;k x;k fd mRrjoknh dz-1@ifjoknh us vksfj;saVy ba";ksjsal daiuh fyfeVsM dh esfMDyse ikWfylh yh Fkh tks fnukad&12-01-2016 ls 11-01-2017 rd FkhA mRrjoknh dz- 1@ifjoknh us tc viuk gsYFk psdvi djk;k rks Vh- ,e- Vh- ikWftfVo // 16 // vkus ij MkWDVj }kjk lh,th ¼,aft;ksxzkQh½ gsrq lykg nh xbZ] fdUrq vihykFkhZ@vukosnd dz-1 }kjk dS"kysl dh lqfo/kk iznku ugha dh xbZA mRrjoknh dz-1@ifjoknh us fnukad&02-03-2016 dks lkvksy gkVZ ds;j lsaVj] jk;iqj esa uSpqjy ck;ikl ,oa ck;ksdsfedy ,aft;ksxzkQh dh VªhVesaV "kq: fd;k ftlds fy, mRrjoknh dz-1@ifjoknh us 1]27]500@&¼,d yk[k lRrkbZl gtkj ikap lkS :Ik;s½ dk Hkqxrku fd;k vkSj esfMdy jsEclZesaV ds fy, fnukad&01-03-2016 dks esfMDyse nkok izLrqr fd;k ftls vihykFkhZ@vukosnd dz-1 us Pre existing disease ds dkj.k jn~n dj fn;k] tcfd mRrjoknh dz-1@ifjoknh dks iwoZ esa dksbZ chekjh ugha FkhA vihykFkhZ@vukosnd dz-1 us bl vk/kkj ij nkok fujLr fd;k fd ikWfylh ubZ Fkh] bl dkj.k Dyse Hkqxrku ;ksX; ugha gS] fdUrq mRrjoknh dz-1@ifjoknh }kjk o'kZ 2012 ls esfMDyse ikWfylh yh tk jgh FkhA o'kZ 2016 esa ikWfylh dks ;qukbZVsM bafM;k ba";ksjsal daiuh fyfeVsM ls iksVsZfcfyVh ds vk/kkj ij fn vksfj;saVy ba";ksjsal daiuh fyfeVsM esa ifjofrZr fd;k x;kA ikWfylh dks iksVZ djkus ds ckn fny dh chekjh dh tkudkjh gqbZ gSA vihykFkhZ@vukosnd dz-1 }kjk Dyse dks Pre existing disease ,oa iksVZfs cfyVh u gksus ds dkj.k Dyse jn~n dj fn;k vkSj iqu% ,d o'kZ ds Ik"pkr~ mlh chekjh ds bZykt dk Hkqxrku fd;k gS tks vihykFkhZ@vukosnd dz-1 dh lsok esa deh ,oa mis{kk dks n"kkZrk gSA 15- vihykFkhZ@vukosnd dz-1 }kjk ;g rdZ fn;k x;k fd mRrjoknh dz-1@ifjoknh ;qukbZVsM bafM;k ba";ksjsal daiuh ls yh xbZ rRle; dh // 17 // ekStwnk esfMDyse ikWfylh dks uohuhdj.k }kjk vihykFkhZ@vukosnd dz-1 daiuh esa f"k¶V djuk pkgrk FkkA mRrjoknh dz-1@ifjoknh iksVZfs cfyVh dh "krksZa ls larq'V Fkk vkSj mRrjoknh dz-1@ifjoknh dks fnukad&12-01- 2016 ls fnukad&11-01-2017 dh ekU; vof/k ds fy, vfHkdfFkr ikWfylh tkjh dh FkhA mRrjoknh dz-1@ifjoknh dk 15]936@&¼iUnzg gtkj ukS lkS NRrhl :Ik;s½ dk Dyse lh,th ¼,aft;ksxzkQh½] nokvksa ,oa lh,th lhMh [kjhnh ds laca/k esa Fkk ftls mRrjoknh dz-2@vukosnd dz-2 Vh-ih-,- us ikWfylh "krZ ds DykWt 4-10 ds rgr chekjh ds vkadyu@y{k.k tkuus ds laca/k esa gksus ds dkj.k fujLr fd;k gSA mRrjoknh dz-1@ifjoknh }kjk EECP vkSj ck;ksdsfedy ,aft;ksIykLVh ds fy, 1]38]000@&¼,d yk[k vM+rhl gtkj :Ik;s½ dk Dyse fd;k ftls ikus ds fy, mRrjoknh dz- 1@ifjoknh ik= ugha gS tks fd mipkj ugha gSA EECP ,d tkap gS] mipkj ugha gSA mRrjoknh dz-3@vukosnd dz-3 ,d Vh-ih-,- gS tks vius fo"ks'kK fpfdRldksa dh jk; vkSj lykg ds vk/kkj ij nkos dk fujkdj.k djrk gSA mRrjoknh dz-1@ifjoknh us vihykFkhZ@vukosnd dz-1 ls ikWfylh fnukad&12-01-2016 dks yh vkSj mlesa lh,Mh chekjh dk y{k.k fnukad&27-02-2016 dks ikWfylh ds izFke o'kZ esa gh vk;k gS bl dkj.k Dyse Hkqxrku ;ksX; ugha gSA 16- mRrjoknh dz-1@ifjoknh }kjk izLrqr ,usD"pj&39 nkok fujLrhdj.k i= gS ftlesa nkos dks fujLr djus dk fuEu vk/kkj fn;k x;k gS%& // 18 // On perusal of claim documents submitted the patient got admitted on 27.02.2016 and got discharged on 28.02.2016 at usha mullapudi cardiac centre Hospitals and was diagnosed with coronary artery disease and was surgical treated for the same. As per discharge summary the claimant was supposed to be known case of CAD. Hence the claim stands denied under Policy Exclusion clause number and description was 4.1-Pre-existing health condition or disease or ailment/injuries: Any ailment/disease/injuries/health condition which are per-existing (treated/untreated, declared/not declared in the proposal form), in case of any of the insured person of the family, when the cover incepts for the first time, are excluded for such insured person upto 3 years of this plicy being in force continuously. This exclusion will also apply to any complications arising from pre existing ailments/disease/injuries. Such complications shall be considered as a part of the pre existing health condition or disease. Hence we regret our inability to admit this liability under the present policy condition.
The denial clause/s with description is/are reproduced below for your ready reference:
Clause Description
Claim stands
denied Pre- existing disease
17- gekjs }kjk izdj.k esa vihykFkhZ@vukosnd dz-1 rFkk mRrjoknh dz- 1@ifjoknh }kjk izLrqr nLrkostksa rFkk lk{;ksa dk ifj"khyu fd;k x;kA vihykFkhZ@vukosnd dz-1 }kjk chek ds fu;e o "krsZa izLrqr dh xbZ gS ftlds viotZu dh dafMdk&4-1 ds vuqlkj%& "4.1 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), in // 19 // case of any of the insured person of the family, when the cover incepts for the first time, are excluded for such insured person upto 3 years of this policy being in force continuously." 18- mRrjoknh dz-1@ifjoknh }kjk ;g esfMDyse ikWfylh vihykFkhZ@vukosnd dz-1 ls izFke ckj fnukad&12-01-2016 dks yh xbZ Fkh rFkk mRrjoknh dz-1@ifjoknh us mDr nkok ikWfylh ysus ds izFke o'kZ esa izLrqr fd;k gS tks viotZu dh dafMdk&4-1 ds varxZr ns; ugha gSA mRrjoknh dz-1@ifjoknh }kjk ;g rdZ fn;k x;k fd mDr ikWfylh iksVsZfcfyVh ds varxZr ifjorZu dh xbZ gS] ubZ ikWfylh ugha gSA bl izdkj mDr nkok viotZu dh dafMdk&4-1 ds varxZr ugha vkrk gSA mRrjoknh dz-1@ifjoknh }kjk vius rdZ ds leFkZu esa izn"kZ ,&8 izLrqr fd;k x;k gS tks vksfj;saVy ba";ksjsal daiuh fyfeVsM dk iksVsZfcfyVh QkeZ gS tks mRrjoknh dz-1@ifjoknh }kjk Hkjk x;k gS] fdUrq mDr QkeZ vksfj;saVy ba";ksjsal daiuh ds le{k izLrqr fd;k x;k Fkk] bldk dksbZ lk{; ugha gSA mDr QkeZ ij vihykFkhZ@vukosnd dz-1 }kjk izkfIr dh dksbZ lhy ;k gLrk{kj ugha gS rFkk mRrjoknh dz-1@ifjoknh }kjk izLrqr izn"kZ ,&47 vihykFkhZ@vukosnd dz-1 }kjk tkjh i= gSA bl i= esa ;g mYysf[kr gS fd %& "Upon referring the matter in the grievance cell of our Regional office, we have been informed by them that this portability facility is not applicable to the Bank- Assurance product which is rated on group basis."
// 20 // mDr i= ls Li'V gS fd mRrjoknh dz-1@ifjoknh dks izkIr ikWfylh ij iksVsZfcfyVh dh lqfo/kk miyC/k ugha gSA 19- mRrjoknh dz-1@ifjoknh }kjk izLrqr izn"kZ ,&62 rFk vihykFkhZ@vukosnd dz-1 }kjk izLrqr izn"kZ&,u,&1@2 esMh vflLV dk i= gSA mDr i= dh dafMdk&4-15 esa fuEu izfof'V dh xbZ gS %& Category Break Up Charge Type Bill Payable Non Pay Non Payable Reason Amount Amount Amount Investigation & 5,200 5,200 0 ---
Lab Charges
Non Taxable 2,636 2,636 13 Face mask-4/-
Pharmacy & surgeon cap-9/-
Medicine
Charges
Package 1,39,500 12,000 1,27,500 Not payable as per
policy. EECP, it is
experimental and
investigation
mDr i= esa EECP ,d tkap gS] mipkj ugha gS tks ikWfylh ds
varxZr ns; ugha gS] fy[kk gSA Vh-ih-,- fo"ks'kK fpfdRldksa dh jk; vkSj lykg ij nkos dk fujkdj.k djrh gSA Vh-ih-,- }kjk izLrqr fjiksVZ ij vfo"okl djus dk dksbZ vk/kkj fo|eku ugha gS vkSj uk gh mRrjoknh dz- 1@ifjoknh }kjk fdlh fo"ks'kK dh fjiksVZ bl laca/k esa izLrqr dh gS fd EECP ,d mipkj gSA vr% mRrjoknh dz-1@ifjoknh dk ;g rdZ fd // 21 // nkok Lohdkj uk dj vihykFkhZ@vukosnd dz-1 us lsok esa deh dh gS] vLohdkj fd;k tkrk gSA 20- mRrjoknh dz-1@ifjoknh us tks U;k; n`'Vkar dk voyacu fy;k gS mlds rF; bl izdj.k ds rF; ls fHkUu gSa] vr% mldk ykHk mRrjoknh dz-1@ifjoknh dks ugha feyrk gSA 21- mijksDr foospuk ds ifjizs{; esa ge bl fu'd'kZ ij igqaps gSa fd mRrjoknh dz-1@ifjoknh dk EECP ls lacfa /kr nkok iz;ksxkRed ,oa tkap ls lacaf/kr gksus rFkk nkok ikWfylh ij iksVsZfcfyVh dh lqfo/kk izkIr uk gksus ds dkj.k ikWfylh dh viotZu dh dafMdk&4-1 ds varxZr ns; ugha gSA ftyk Qksje us chek "krksZa dk voyksdu uk dj esfMDyse nkok Lohdkj dj =qfV dh gS ftlesa gLr{ksi dh vko";drk gSA vr% vihykFkhZ@vukosnd dz-1 }kjk izLrqr vihy Lohdkj fd;s tkus ;ksX; gSA 22- vr% vihykFkhZ@vukosnd dz-1 }kjk izLrqr vihy Lohdkj dh xbZA ftyk Qksje }kjk ikfjr vkyksP; vkns"k fnukad&02 vizSy 2019 vikLr fd;k x;kA ifj.kke Lo:Ik mRrjoknh dz-1@ifjoknh dk ifjokn fujLr fd;k x;kA bl vihy dk O;; i{kdkj viuk&viuk ogu djsaxsA ¼ U;k;ewfrZ lh- ch- cktis;h ½ ¼Jherh :fp xks;y½ v/;{k lnL;k 09@01@2020 09@01@2020