Ref : ER/Press/04/piyush.51/sam

Oriental Insurance Ordered to Reimburse Rs 39,928 as Mediclaim

In response to a complaint filed by Consumer Education and Research Society (CERS), Ahmedabad, and Piyush Chaturbhai Patel about his Mediclaim, the Consumer Disputes Redressal Forum, Ahmedabad City, has ordered Oriental Insurance Company to pay him Rs 39,927.99 (Repeat Rs 39,927.99) with 8 per cent interest from 19 August 1997 till realisation. The complaint pertained to non-reimbursement of his hospital expenses by the company despite his holding a Mediclaim policy.

Piyush, his wife and son had taken a joint medical insurance policy from 23 August 1996 to 22 August 1997. On 7 June 1997 he consulted Dr. Sumant S. Shah, an orthopedic surgeon, for backache. Dr. Shah prescribed medicines and advised rest. On 11 June, his condition deteriorated, his urine and stool passage stopped and paralytic effect was noticed on the lower half of his body.

On 12 June 1997, Piyush was admitted to the Karnavati Hospital, operated on for Koch’s spine D9 (tuberculosis of the spinal cord) and discharged on 28 June 1997.

He submitted the mediclaim on 19 August 1997 but, seven months later, on 16 March 1998, the company repudiated his claim on grounds that the disease had been pre-existing and the insured had concealed material facts in the proposal form.

On 19 December 1997, Piyush wrote to the company that he had been suffering from epilepsy and undergoing treatment since 1956. He explained that he had not thought it necessary to state it in the proposal form as he had never needed any hospitalisation during the treatment of epilepsy for the last 40 years. The insurance company, however, persisted in its refusal to sanction reimbursement.

CERS pleading for Piyush, cited several cases and explained that the failure to mention some minor ailment could not be construed as fraudulent suppression of material facts. Besides, the claim was prayed for the expenditure incurred in the operation of tuberculosis.

Quoting Supreme Court observations in a similar case, the Forum considered the view that the non-disclosure of Piyush’s diseases like epilepsy, hypertension and backache would not amount to suppression of material facts. The Forum directed the insurance company to pay Piyush Rs. 39,927.99 with 8 per cent interest from 19 August 1997 till realisation. The company was further directed to pay Piyush Rs. 2000 each for mental agony and cost.

Mr. U. M. Raval presided over the Forum with Mr. B. H. Joshi as Member.

Mrs. Nayana S. Shah, advocate, appeared for the opponent and Mr. K. H. Khatwani for CERS.

Date : 03/11/2004
Place : Ahmedabad

Pritee Shah
Editor
INSIGHT - The Consumer Magazine

 

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CONSUMER EDUCATION AND RESEARCH SOCIETY
“Suraksha Sankool”, Thaltej, Sarkhej-Gandhinagar Highway, Ahmedabad - 380 054 (INDIA)
Phone: 079-27489945-46 Fax: 079-27489947
E-mail: cerc@wilnetonline.net
Web Site: http://www.cercindia.org
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