Ahmedabad Ombudsman Centre
Case No. NIC / 1 / 103
Shri Dinesh P. Vashisht
Vs.
National Insurance Co. Ltd.
Complainant’s wife underwent an ear operation due to discharging from ear. Claim was repudiated under Exclusion Clause 4.1. Complainant submitted that the IP was covered under Mediclaim Policy from 2001 and hence the repudiation is unjustified on the ground of pre – existence of her problem. Respondents submitted that their MR opined that the Insured was suffering from Bilateral Chronic Mastoiditis and that discharging from ear is a chronic problem. Documents and submissions perused. It is observed that the MR of the Respondent has endorsed all aspects of treatment except that he considered the disease to be pre – existing “in all likelihood” which is not a definitive opinion. The clinical history recorded in the Treating ENT Hospital as ear problem for 4 months is considered to be credible, particularly when there is no evidence available to disprove it. Respondent to pay Rs. 12,542/- as FFS to the complainant.
