Ahmedabad Ombudsman Centre
Case No. UIC / 1 / 154
Dr. K. T. Patel
Vs.
United India Insurance Company Ltd.
Smt. S. K. Patel underwent Laminectomy and Lateral Foraminotomy. Claim was lodged after the prescribed time limit and hence it was repudiated. On explanation and representation to CRC, they examined the case on merit and sought expert opinion of their MR who in turn submitted his Report with the opinion that Spinal Canal Stenosis is a degenerative affection of Spinal Column that develops and progresses slowly over a period of several years. Complainant submitted that though the disease might have started earlier, it was known recently when the symptoms manifested. Documents and submissions perused. It is observed that since the Respondent considered the case on explanation of the complainant the efflux of time was impliedly waived by them. Their MR concluded his Report by stating that if the Policy is only since Feb. 2001, then the ailment can be considered as pre -existing. Complainant produced a copy a Money Receipt dated 22.1.99 of payment of premium paid for Mediclaim Cover. From this, it is established that the policy was in force since 1999. The discharge summary of Treating Hospital also showed that the disease manifested before 6 months prior to surgery. Respondent to pay Rs. 76,450/-. Admission fee, Surcharge and other Hospital service expenses are to be deducted from the claim amount.
