The apex consumer commission has asked an insurance firm to reimburse Rs 1.5 lakh medical claim to a man, saying it cannot be presumed that certain expenses incurred in treatment were excluded from the cover.
"Merely because it has been mentioned that insurance under the policy was subject to conditions, clauses, warranties, exclusion etc. Attached, (and) in the absence of attaching conditions, exclusion, etc., it cannot be presumed that expenses incurred in treatment of disease were excluded from the coverage," the National Consumer Disputes Redressal Commission (NCDRC) said.
The commission made the observation as it dismissed a revision petition filed by Star Health and Allied Insurance Company Limited against the State Commission's order to reimburse over Rs 1.5 lakh to Haridas C K, a Kerala resident.
Haridas had taken an insurance policy of Rs 2 lakh but was denied the claim when he got hospitalised.
The NCDRC bench, while granting him the relief, said "I do not find any illegality, irregularity or jurisdictional error in the impugned order and revision petition is liable to be dismissed."
According to the complaint, Haridas was admitted to a hospital in Kerala with chest pain on February 10, 2012, and underwent angioplasty. He was discharged on Febraury 13, 2012.
It alleged that his claim made on March 15, 2012 for the reimbursement of the expenses of Rs 1,62,522 was rejected by the insurance company on April 28, 2012, on the basis of exclusion clause in the policy schedule.
He submitted that there was no such condition at the time of issuing the policy and receiving the premium.
The insurance firm contended that the schedule attached with policy contained the exclusion clause.
The Commission noted that the firm remained ex-parte before District Forum and before the State Commission despite the opportunities given to it.
The NCDRC had dismissed the firm's application for taking the exclusion clause on record in October last year. "Once exclusion clause is not on record, order passed by learned State Commission dismissing appeal is in accordance with law, as there was no exclusion clause attached to the policy," the Commission said.
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