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Mediclaim

      
          

  • Ahmed
    Rashid Abdul Majid Bhuraveala v United
    India Insurance Co Ltd.

    1996(1) CPJ 384 (Gujarat SCDRC)

      

    The complainant had fracture shaft of
    right humerus on 13.1.1981 , and a
    nailing was done. In Nov 1991 the nail
    broke and a second operation was done
    for which the total expenditure of Rs
    25,957/-was incurred. He suffered loss
    of income tothe extent of Rs 36,702/-.
    Also anj additional amount of Rs
    1,05,000/- was claimed on account of
    permanent disability of right arm. The
    above amounts were claimed from the
    opposite party under mediclaim policy
    taken by him. The insurance company
    refused to make payment on the ground
    that the injury on respect of which
    the complainant had advanced claim was
    an old injury not covered by the
    policy. the state commission held that
    the complainant had fully recovered
    from the injury which he had sustained
    in 1981. Injury caused due to breaking
    of nail in 1991 was a fresh injury and
    not an old one and therefore the
    complainant was entitled to claimto
    the extent of actual expenses
    incurredin the treatment.

      

  • Oriental
    Insurance Co v Miss Amisha Jain 

    1996 (2) CPJ 183 (Delhi SCDRC)

      

    Mr Pankaj Jain obtained a mediclaim
    policy jointly with his 9 year old
    daughter Amisha from the Oriental
    Insurance Co on 3.8.91. It was renewed
    on 24.8.92.

      

    In April 93 Amisha fell ill and it was
    found to be a case of hole in the
    heart (V.S.D) and operated upon 
    in AIIMS. Claim was repudiated on
    ground that the father of the minor
    had concealed the heart problem while
    obtaining the policy.

     

    The state commission held taht it is a
    medical fact that symptoms of the
    disease in this case may appear late
    and are not easy to detect.

       

    The order of District Forum who had
    awarded the claim was upheld.

      

  • Joseph
    Ollapally & Ors v The New India
    Assurance Co Ltd & Ors

    1996 (3) CPJ 528 (karnataka SCDRC)

       

    The complainant pending enquiry passed
    away . His legal Representatives were
    brought on record.

     

    The complainant a retired army officer
    obtained an overseas mediclaim policy
    when he was on visit to America.
    During this visit he suffered acute
    stroke, and treated there. On return
    to India the medical expenses bill of
    US $ 35000/- equivalent to about Rs 7
    lakhs was submitted to the Oriental
    Insurance Co. the claim was repudiated
    on the ground that the fact of his
    suffering from hypertension while
    obtaining the policy was suppressed.
    Also while taking the extension of the
    policy the ailment with which he was
    suffering in America was not
    disclosed.

      

    The State Commission noted that the
    National Commission in LIC of India v
    Sanjeev Mahendra Lal Shah was held as
    under:

    ” In life insurance policies, as
    assured it is not required to disclose
    casual ailments not requiring
    treatment or consultation of medical
    doctor and the sickness ailment which
    is required to be disclosed with
    reference to serious disorders in
    health.”

      

    From the medical records it is clear
    that that the hypertension that was
    found on the compliainant was a casual
    ailment. The State commission held
    that the repudiation of the claim of
    the complainant on this ground by the
    opposite party  was not
    justifiable and directed the opposite
    party no 1 to pay to the L.Rs the sum
    which they had produced as proof of
    being spent on medical treatment in
    USA ie US $1882 equal to 37640/-

       

  • New
    India Assurance Co Ltd & Anr v P.P
    Khanna

    1997(2) CPJ 1 NCDRC

      

    The complainant was granted on
    17.1.1991 the hospitalisation
    domiciliary benefit policy by the New
    India Assurance Co Ltd . He
    subsequently underwent angiotherapy
    and Coronary Artery Bypass surgery.The
    claim of Rs 1,29,519 was repudiated by
    the insurance co. on grounds that the
    complainants had not disclosed
    material facts, viz hypertension or
    pain in the chest at the time of
    proposing for the insurance policy.
    The state commission didnot accept
    this contention and allowed this
    complaint.

      

    On appeal against the order of the
    state commission, the national
    commission first enunciate the
    relevant law on the point :

    The Onus probandi  in
    cases of fraudulent suppression of
    material facts rests heavily on the
    party alleging fraud namely the
    insurer. The insurer The insurer
    cannot avoid consequences of insurance
    contract by simply showing inaccuracy
    or falsity of statement . Burden is on
    the insurer to show that the statement
    was on a material matter  or
    facts have been suppressed which it
    was  material for the policy
    holder to disclose. It is further to
    be proved that  the statement was
    fraudulently made by the policy holder
    with the knowledge of of the falsity
    of statement or that the suppression
    was of material facts which had not
    been disclosed. The courts will not be
    satisfied with proof which falls short
    of showing that the intentional
    misrepresentation was made with the
    knowledge of perpetrating fraud.

      

    The national Commision upheld the
    decision of the State Commission that
    the material placed on record by the
    insurance co was not of the
    complainant but of his son who had the
    same initials. There was no reliable
    or convincing material to substantiate
    their allegations.

      

    Appeal of the insurance company was
    dismissed.

      

  • Chaman
    Singh  Faujdar & Ors v German
    Remedies Ltd.

    1992 (2)  CPJ 915 : 1992 (1)
    CPR 603 (RAJ SCDRC).

        

    The complainant purchased one ampoule
    of Deriphyllin injection to be given
    intravenously to his mother. While
    preparing for the injection the doctor
    saw some black pieces in the ampoule
    and gave a cerificate that there was a
    foreign particle in the ampoule and as
    such it was unfit human consumption. 
    Compensation Of Rs 500 in addition to
    the cost of the ampoule Rs 1.62 was
    awarded to be paid by the
    manufacturers M/s German Remadies Ltd.
    The complaint against the chemist was
    dismissed on the ground that he was
    merely selling the ampoule.

       


       


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What is Law     Right of Doctors     Responsibilities     Negligence     Consents     Records     Cases
       
Legislations     Medical Ethics      FAQ’s

   
    

Mediclaim
      
          

  • Ahmed Rashid Abdul Majid Bhuraveala v United India Insurance Co Ltd.
    1996(1) CPJ 384 (Gujarat SCDRC)
      
    The complainant had fracture shaft of right humerus on 13.1.1981 , and a nailing was done. In Nov 1991 the nail broke and a second operation was done for which the total expenditure of Rs 25,957/-was incurred. He suffered loss of income tothe extent of Rs 36,702/-. Also anj additional amount of Rs 1,05,000/- was claimed on account of permanent disability of right arm. The above amounts were claimed from the opposite party under mediclaim policy taken by him. The insurance company refused to make payment on the ground that the injury on respect of which the complainant had advanced claim was an old injury not covered by the policy. the state commission held that the complainant had fully recovered from the injury which he had sustained in 1981. Injury caused due to breaking of nail in 1991 was a fresh injury and not an old one and therefore the complainant was entitled to claimto the extent of actual expenses incurredin the treatment.
      

  • Oriental Insurance Co v Miss Amisha Jain 
    1996 (2) CPJ 183 (Delhi SCDRC)
      
    Mr Pankaj Jain obtained a mediclaim policy jointly with his 9 year old daughter Amisha from the Oriental Insurance Co on 3.8.91. It was renewed on 24.8.92.
      
    In April 93 Amisha fell ill and it was found to be a case of hole in the heart (V.S.D) and operated upon  in AIIMS. Claim was repudiated on ground that the father of the minor had concealed the heart problem while obtaining the policy.
     
    The state commission held taht it is a medical fact that symptoms of the disease in this case may appear late and are not easy to detect.
       
    The order of District Forum who had awarded the claim was upheld.
      

  • Joseph Ollapally & Ors v The New India Assurance Co Ltd & Ors
    1996 (3) CPJ 528 (karnataka SCDRC)
       
    The complainant pending enquiry passed away . His legal Representatives were brought on record.
     
    The complainant a retired army officer obtained an overseas mediclaim policy when he was on visit to America. During this visit he suffered acute stroke, and treated there. On return to India the medical expenses bill of US $ 35000/- equivalent to about Rs 7 lakhs was submitted to the Oriental Insurance Co. the claim was repudiated on the ground that the fact of his suffering from hypertension while obtaining the policy was suppressed. Also while taking the extension of the policy the ailment with which he was suffering in America was not disclosed.
      
    The State Commission noted that the National Commission in LIC of India v Sanjeev Mahendra Lal Shah was held as under:
    ” In life insurance policies, as assured it is not required to disclose casual ailments not requiring treatment or consultation of medical doctor and the sickness ailment which is required to be disclosed with reference to serious disorders in health.”
      
    From the medical records it is clear that that the hypertension that was found on the compliainant was a casual ailment. The State commission held that the repudiation of the claim of the complainant on this ground by the opposite party  was not justifiable and directed the opposite party no 1 to pay to the L.Rs the sum which they had produced as proof of being spent on medical treatment in USA ie US $1882 equal to 37640/-
       

  • New India Assurance Co Ltd & Anr v P.P Khanna
    1997(2) CPJ 1 NCDRC
      
    The complainant was granted on 17.1.1991 the hospitalisation domiciliary benefit policy by the New India Assurance Co Ltd . He subsequently underwent angiotherapy and Coronary Artery Bypass surgery.The claim of Rs 1,29,519 was repudiated by the insurance co. on grounds that the complainants had not disclosed material facts, viz hypertension or pain in the chest at the time of proposing for the insurance policy. The state commission didnot accept this contention and allowed this complaint.
      
    On appeal against the order of the state commission, the national commission first enunciate the relevant law on the point :
    The Onus probandi  in cases of fraudulent suppression of material facts rests heavily on the party alleging fraud namely the insurer. The insurer The insurer cannot avoid consequences of insurance contract by simply showing inaccuracy or falsity of statement . Burden is on the insurer to show that the statement was on a material matter  or facts have been suppressed which it was  material for the policy holder to disclose. It is further to be proved that  the statement was fraudulently made by the policy holder with the knowledge of of the falsity of statement or that the suppression was of material facts which had not been disclosed. The courts will not be satisfied with proof which falls short of showing that the intentional misrepresentation was made with the knowledge of perpetrating fraud.
      
    The national Commision upheld the decision of the State Commission that the material placed on record by the insurance co was not of the complainant but of his son who had the same initials. There was no reliable or convincing material to substantiate their allegations.
      
    Appeal of the insurance company was dismissed.
      

  • Chaman Singh  Faujdar & Ors v German Remedies Ltd.
    1992 (2)  CPJ 915 : 1992 (1) CPR 603 (RAJ SCDRC).
        
    The complainant purchased one ampoule of Deriphyllin injection to be given intravenously to his mother. While preparing for the injection the doctor saw some black pieces in the ampoule and gave a cerificate that there was a foreign particle in the ampoule and as such it was unfit human consumption.  Compensation Of Rs 500 in addition to the cost of the ampoule Rs 1.62 was awarded to be paid by the manufacturers M/s German Remadies Ltd. The complaint against the chemist was dismissed on the ground that he was merely selling the ampoule.
       

       

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By |2022-07-20T16:43:45+00:00July 20, 2022|Uncategorized|Comments Off on Patient’s Favour / Mediclaim

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