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Showing contexts for: Problem in National Insurance Co. Ltd. vs Mahendra Singh on 4 August, 2009Matching Fragments
2. It arises in the following circumstances-
That the complainant respondent had filed a complaint against the appellants before the District Forum, Jaipur on 16.6.08 inter alia stating that the complainant respondent had taken a Medi Claim Policy for himself on 18.10.02 for one year and thereafter he had got that policy renewed w.e.f. 17.10.03 and under the renewed policy apart from the complainant respondent, his wife Smt. Jyoti, Divaspati ( son) Shivani ( daughter) and Vagmita ( daughter ) were also got insured and in other words they were also members of the medi claim policy which was in force w.e.f. 17.10.03. It was further stated in the complaint that thereafter the said policy was again renewed by the complainant respondent on 12.10.04 for one year and in the renewed policy the members were the same. It was further stated in the complaint that his son Divaspati who is also one of the insured persons in the policy, had developed ear problem with pus discharge and pain in the month of July 2004 and for that he had consulted several doctors and on the basis of the diagnosis it was found that the pus discharge and pain were related to posterior right ear retraction pocket as a result of which patient had also developed hearing loss and apart from some problem in the ear his son was having problem of deviation in the nasal septum known as DNS ( Deviated Nasal Septum ). It was further stated in the complaint that thereafter his son Divaspati was got admitted in the SMS Hospital, Jaipur in the Unit of Dr. S.P.Srivastava, ENT surgeon on 19.10.04 and was discharged on 20.10.04 and the diagnosis which was made by the doctor was DNS and in the pre operative note it was also mentioned that he was a patient of cold, cough and hearing loss since childhood and that is marked as Anx. R-1. and operation of Septoplasty was done . It was further stated in the complaint that a claim for a sum of Rs. 5,299/- was submitted by the complainant respondent for re-imbursement being the expenses incurred in connection with the said hospitalization and operation but that claim was repudiated by Paramount Health Services Pvt. Ltd. on behalf of the appellants through letter dated 14.12.04 ( Anx. R-4 ) in the following manner-
" This is to certify that Mr. Divaspati Singh who was under my care suffered from recurrent cold and cough since childhood. Seven months ago he had a sproblem of pus discharge from his right ear which caused partial hearing loss. He underwent septoplasty on 20.10.04 to correct a deviation in his nasal septum."
It was further stated in the complaint that thereafter Divaspati was got admitted in the Cumballa Hill Hospital and Heart Institute, Mumbai on 21.12.04 with the problem in his right ear and operation was done by Dr. Milind V. Kirtane on 22.12.04 to cure the problem of right ear posterior quadrant retraction pocket and he was discharged from that hospital on 23.12.04. It was further stated in the complaint that a sum of Rs. 50,400/- were spent by the complainant respondent for the hospitalization, operation and treatment at Mumbai and the claim was preferred by the complainant respondent before the office of the appellants on 13.1.05 but that claim was repudiated by Paramount Health Services Pvt. Ltd. on behalf of the appellants through letter dated 2.4.05 ( Anx. R-8) in the following manner-
It was further stated in the complaint that on 22.4.05 a letter was sent by Paramount Health Services Pvt. Ltd. justifying the decision already taken by the appellants to repudiate the claim. It was further stated in the complaint that repudiation in respect of both claims by Paramount Health Services Pvt. Ltd. on behalf of the appellants through letters dated 14.12.04 and 2.4.05 was not justified at all as the DNS problem is not a problem that could be treated as pre-existing disease and thus there was no suppression of material facts on the part of the complainant respondent at the time of taking the medi claim policy for his son and thus there was deficiency in service on the part of the appellants in repudiating the claim of the complainant respondent and for that deficiency the present complaint was filed by the complainant.
25. Pre-existing disease is one for which the insured should have undergone hospitalisation or undergone long treatment or operation. Otherwise, for laymen these day to day normal problems are not to be disclosed as even otherwise medical terminology of such problems is difficult to understand and know.
26. Merely because some positive science in respect of so called disease are noticed later on, but for that; that disease could not be treated as pre-existing disease.
27. It may be stated here that a person might be suffering from a disease but he may not take care to that and go to a doctor. Quite often a person, who might be having some problem with the heart may not be knowing about it and may not go to a doctor. The question always, which has to be determined, is, was the pre-existing disease to the knowledge of the insured. That knowledge could be attributed if the person takes some or the other treatment from a doctor/hospital and on point of pre-existing disease the law laid down by this Commission in the case of New India Assurance Co. Ltd. Vs. Vishwanath Manglunia ( ( 2006 ) 3 CPJ 68 ) may be referred to.