
Heart
surgery expenses reimbursed
Tribune
News Service
CHANDIGARH, June 25
The UT Consumer Disputes Redressal Forum-II has
directed National Insurance Company to pay Rs 1,46,350
spent on heart surgery to a complainant under its
medi-claim policy.
Mr Om Parkash Goel, a
resident of Panchkula, had taken a medi-claim policy from
National Insurance Company for the period from June 29,
1995, to June 28, 1996. Thereafter he suffered chest pain
on August 6, 1995, and was taken to a nursing home in
Sector 9, Panchkula. He was then referred to Escorts
Heart Institute, New Delhi, where he underwent a heart
bypass surgery. This cost him Rs 1,46,350, including Rs
14,750 spent on various tests and angiography.
He claimed this amount
from the insurance company under the medi-claim policy
but the same was rejected.
The insurance compnay in
its reply justified the rejection of the claim on the
ground that the complainant was already suffering from a
heart ailment before he took the policy. And, therefore,
his claim fell under the exclusion clause of the policy.
The company relied upon a report of Dr Rakesh Soni who
contended that the complainant had purchased the
medi-claim policy in contemplation of undergoing surgical
treatment. He further stated that the complainant did not
disclose the heart problem while taking the policy.
The forum Bench
comprising its President R.P. Bajaj and member H.S.
Walia, after going through the records, observed that the
report of Dr Soni was not supported by an affadavit. It
further held that ``he is a simple MBBS doctor and not a
cardiologist. The reasons given by him are just surmises
and based on possibilities which are not cogent enough to
give a positive finding that the complainant was
suffering from heart diseases prior to his taking the
policy.''
While Dr Soni did
observe in his report that the complainant was suffering
from pre-existing coronary artery disease as shown in the
ECG report, but he did not pinpoint the precise malady in
the ECG report to prove that it was a case of an old MI.
Hence, the report appeared to have been prepared with a
pre-determined mind to negate the claim of the
complainant. Furthermore, there was no evidence to show
that the complainant was ever hospitalised before August
6, 1995, for a heart ailment or he had consulted any
doctor in this regard prior to that.
The forum, therefore,
held that the repudiation of the claim was an act of
deficiency in service on the part of the company. The
company did not collect any material to prove that the
complainant was actually suffering from a heart ailment
prior to his taking the policy.
The forum directd the
insurance company to pay the amount actually spent on the
heart surgery amounting to Rs 1,46, 350 along with an
interst at the rate of 12 per cent per annum from May 24,
1996, till the payment. The costs of Rs 1,500 were also
imposed.
Case
settled
The Electricity
Department, UT, has agreed to allow a refund of Rs 5,900
out of the sundry charges wrongly levied upon a consumer.
Genuine Auto Spares, a
tenant in one of the showrooms in Sector 28, had filed a
complaint alleging that the Electricity Department had
wrongly levied sundry charges of Rs 8,996 in the bill of
November 17, 1998, for the period from August 21, 1998,
to October 21, 1998. These charges were levied on the
pretext that the meter was defective during the earlier
period.
However, the complainant
challenged the calculation of average charges before the
forum.
During the period of the
complaint, the SDO settled the matter with the
complainant.
Therefore, the forum
disposed of the matter.
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