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Showing contexts for: CONGENITAL DISEASE in New India Assurance Co. Ltd. vs Dr. S. S. Kansal on 29 October, 2015Matching Fragments
"Your claim file was referred to our panel doctor for his technical opinion. As per our panel doctor the disease suffered by you is a manifestation of congenital disease which is not covered as per exclusion no. 4.3 of the policy conditions. The competent authority has accordingly repudiated your claim which please note.
The inconvenience caused is regretted."
3. Being aggrieved of the repudiation of mediclaim, the complainant raised a consumer dispute. The petitioner on being served with the notice filed written statement and pleaded that mediclaim of complainant was rightly repudiated because the disease suffered by him was congenital disease, which is not covered for indemnification as per Exclusion Clause 4.3 of the policy condition.
6. Ms. Shuchi Singh, Advocate for the petitioner has contended that impugned order of the foras below are not sustainable because both the foras below have failed to appreciate that the disease for which the mediclaim was filed was a congenital disease and in view of Exclusion Clause 4.3 of the insurance contract, the insurance company was not liable to reimburse the expenses incurred on the treatment of the said disease. In support of this contention, learned counsel for the petitioner has taken us through the medical literature particularly page 139. Relevant medical literature is reproduced herein below:
7. In order to succeed in this argument, counsel for the petitioner is required to show that the treatment for which the mediclaim was filed was the manifestation of a congenital disease. On reading of the medical literature cited above, it is clear that there are so many causes which may cause enlarged heart and one of those cause is genetic and inherited condition. Counsel for the petitioner has failed to point out any evidence which may show the exact cause of the disease suffered by the complainant for which he had to undergo surgery. In absence of conclusive evidence that the surgery for which the mediclaim was filed was the manifestation of the congenital disease, the concurrent finding of fact returned by foras below cannot be faulted.