Ahmedabad Ombudsman Centre
Case No. 14 – 002 – 0007
Smt. Hasumati J. Patel
Vs.
The New India Assurance Company Ltd.
Repudiation of Mediclaim. Complainant’s husband underwent Abdominal Rectopexy and repair of Right Inguinal Hernia. Claim Repudiated u / c 4.1 Complainant submitted that the disease was of 6 months old and it was detected by the Treating Surgeon in course of examination. Respondents submitted that they referred the case to two Consulting Surgeons for their opinion since the claim was in the second year of the Policy.
Both Doctors ascertained in their opinions that the disease was of 4 / 5 years. Moreover, one of the MRs obtained a statement from the Insured as well as from the Complainant stating that the Insured had bleeding P / R problem since 1992 – 93 and also problem of Inguinal Hernia for 4 to 5 years. Documents and submissions perused. It is observed that the treatment administered is in conformity with the disease diagnosed and the expenses incurred therein are not in dispute. The point for determination is whether the Respondent could prove that the disease was pre – existing vis – à – vis the inception of the Cover on 25.08.2000.
Since the opinion of Treating Surgeon and the opinions of MRs were of vide difference, the statement obtained from the Insured and the Complainant by one of the MRs has been taken as an important document to determine the issue of pre – existence of disease.
Accordingly, it is established that the disease was pre – existing. Repudiation sustained. Complaint dismissed without any relief.
