New Delhi Consumer Disputes Redressal Forum, presided by C K Chaturvedi,
asked the Oriental Insurance Company Ltd to pay Rs 92,696 to Delhi resident
Sachin Tayal, who was insured by the company from 2007, who had submitted a
claim after his minor child was admitted at a hospital here for removal of
adenoids (enlarged lymphatic tissue) on January 31, 2011.
The Insurance company rejected the claim on the ground that as per policy congenital defects are excluded, and that complaint of snoring, fever and difficulty in hearing were pre-existing diseases.
In its order, the forum noted that the problem for which complainant’s son was admitted in the hospital was not a disease but medical condition.
“…The adenoids in children is a common phenomena leading to fever, difficulty in hearing as ear, nose, throat are interconnected, and the treatment is only removal of growth of soft tissues in throat and insertion of grommets in ears. These are not diseases but medical condition. In no case it can be called congenital disease,” it said.
“…We find that Opposite Party (company) has not applied its mind and arbitrarily repudiated a just claim,” the forum’s bench, also comprising its members S R Chaudhary and Ritu Garodia, said.
The forum held the company guilty of deficiency in service. It directed the firm to pay the claim amount of Rs 47,696, besides Rs 25,000 for deficiency, harassment and mental agony and Rs 20,000 for the litigation
The Insurance company rejected the claim on the ground that as per policy congenital defects are excluded, and that complaint of snoring, fever and difficulty in hearing were pre-existing diseases.
In its order, the forum noted that the problem for which complainant’s son was admitted in the hospital was not a disease but medical condition.
“…The adenoids in children is a common phenomena leading to fever, difficulty in hearing as ear, nose, throat are interconnected, and the treatment is only removal of growth of soft tissues in throat and insertion of grommets in ears. These are not diseases but medical condition. In no case it can be called congenital disease,” it said.
“…We find that Opposite Party (company) has not applied its mind and arbitrarily repudiated a just claim,” the forum’s bench, also comprising its members S R Chaudhary and Ritu Garodia, said.
The forum held the company guilty of deficiency in service. It directed the firm to pay the claim amount of Rs 47,696, besides Rs 25,000 for deficiency, harassment and mental agony and Rs 20,000 for the litigation
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