Ahmedabad Ombudsman Centre
Case No. 11 / 002 – 0027
Mr. Hasmukh M. Shah
Vs.
The New India Assurance Company Ltd.
Complainant’s wife underwent TKR. Claim repudiated under Clause 4.1. Complainant submitted that his Mediclaim Policy was in force from 1989 to 2002 – 03 without any break initially with United India and then with the Respondent since 1997. This was his first claim since inception and the claim amount is much lower than the actual expenses. Based on two X – Ray Reports taken in 1998, the core argument put forward by the Respondent was that osteoarthritis changes like reduction in joint space, tibia vara as early as 1988.
Documents and submissions perused. It is observed that the subject surgery took place in 2002 after 14 years of inception of Policy in 1988 and the Respondent has no evidence of treatment in between 1988 and 2002. The complaint neither enhanced the SI nor made any claim during the period except the subject claim and the Policy has earned C.B,. as well.
Further, the 1988 X – Ray Reports were submitted by the Complainant himself to the Respondent, otherwise they would not have opportunity to get a clue into these documents which they relied to repudiate the claim. No weightage has been given to these X – Ray Reports for denying the benefits to a loyal Policy Holder. Repudiation set aside. Respondent to pay Rs. 25,000/- to the Complainant as FFS.
