Consumer Education and Research Society (CERS), Ahmedabad, and Ms Reshma Trivedi Vs United India Insurance Company

The Consumer Disputes Redressal Forum, Ahmedabad (Rural), has partly allowed a complaint filed jointly by Consumer Education and Research Society (CERS), Ahmedabad, and Ms Reshma Trivedi, holding United India Insurance Company liable for negligence and deficiency in service.

The Forum has ordered the company to pay Reshma Rs 30,000 towards her mediclaim policy with 9 per cent compound interest from the date of complaint till realisation and Rs 5,000 towards cost, according to a CERS release here today.

Reshma had taken a mediclaim policy of United India Insurance Company on October 27, 2000, and renewed it in 2001 till October 27, 2002. Reshma had undergone a hernia operation for the second time in May 2002, for which she filed a claim of Rs 27,500 on May 10, 2002. The company rejected her claim saying that the ailment (hernia) was present when she had applied for the policy.

The company, after consulting its panel doctor, had reasoned that Reshma had undergone caesarean and hysterectomy operations, due to which she suffered from hernia for the first time and subsequently for the second time too. The hernia, she was operated for, was existing while she took the mediclaim and she had not specified the information under the pre-existing clause. United India Insurance, therefore, took the stand that in her case hernia was a pre-existing disease and, therefore, the exclusion clause was applicable.

CERS contended that it was the responsibility of the insurance company to prove that in Reshma case hernia was a pre-existing disease and that the occurrence of hernia had in no way any relation with her hysterectomy and caesarean operations.

The Forum partly allowed the complaint and directed United India Insurance to pay Reshma Rs 30,000 of the mediclaim policy with 9 per cent compound interest from the date of complaint till realisation. United India Insurance was also directed to pay Rs 5,000 towards cost to her.