Ahmedabad Ombudsman Centre
Case No. NIA / 1 / 298
Smt. Abha N. Shah
Vs.
The New India Assurance Company Ltd.
Complainant’s 9-year- old daughter underwent Appendectomy. Claim repudiated on the grounds of pre – existence of disease. Complainant submitted that due to severe abdominal pain, they consulted their family Physician who referred the case to Dr. A. P. Munshi. Dr. Munshi diagnosed the disease as Appendicitis and advised operation.
Respondents submitted that according to their MR, who obtained a statement from the Complainant, the Insured was having the disease for the last 2 years, and hence the disease existed prior to the inception of the Cover. During the hearing, the Complainant submitted that she does not know the meaning of “Conservative treatment”, and explained that the MR of the Respondent Dr. Y. C. Shah asked her whether the child had pain in the stomach ever and she recalled 2 years back there was some such pain and for that she consulted Dr. Desai who prescribed medicines and cured the pain. Documents and submissions perused. Explanation of the Complainant found convincing though she had signed the statement.
Even Though Dr. Desai’s Chamber was very near to the house of the Complainant, Dr. Shah chose not to visit Dr. Desai and get clarification from him. It is also opined that a disease of potential danger to the life of a child was allowed for 2 years through conservative treatments is a difficult position to reconcile.
Weightage has been given to Dr. Desai’s certificate produced by the Complainant during the hearing. Repudiation set said. Respondent to pay Rs.19088/- as FFS to the Complainant.
