Miscellaneous Policy (General) - Gbic.co.in

Charitable Trust Hospital for renal allografting from 26.2.2002 to 15.3.2002. He submitted amediclaim for Rs 1,47,323. It was repudiated on 23.6.2003 on the ground that the treatmentpertained to a pre existing disease, since hers was a known case of hypertension.Aggrieved by the decision, he filed a complaint contending that his daughter-in-law did nothave any symptoms of the disease earlier, nor was she aware of it.FINDINGS : The perusal of the discharge summary revealed that the insured had a historyof hypertension since November, 2001 and was a known case of polycystic kidney.Besides, claims relating to congenital internal diseases are not entertainable during firstyear of the policy under exclusion clause 4.3 which stipulates that “ during the first year ofthe operation of insurance cover, the expenses on treatment of diseases such as cataract,benign prosthetic hypertrophy, hysterectomy for menorrhagia or fibromyoma, hernia,hydrocele, congenital internal disease, fistula in anus, piles, and sinusitis and relateddisorders are not payable.”DECISION : It was established on the basis of documentary evidence that the claimant wasa patient of H.T since November, 2001, which is a direct complication of polycystic kidney.The discharge summary and the medical certificate issued by the Consultant Nephrologistalso confirmed that it was a pre-existing disease. Held that the claim was, therefore,rightly repudiated under the terms and conditions of the policy. The claim was otherwisealso not admissible under the exclusion clause 4.3 of the policy as it pertained to acongenital disease during the first year of the policy.Chandigarh Ombudsman CentreCase No. GIC/73/NIA/11/05Salil AggarwalVs.New India Assurance Co.Award dated: 31.1.2005FACTS : Shri Salil Aggarwal had taken a Adhikari Suraksha Kavach policy from BO,Gurgaon for the period from 18.1.2002 to 17.1.2003, which inter alia, covered a laptop. Thelaptop was stolen from his car on 9.1.2003. He lodged an FIR and informed the insurer. Asurveyor was deputed who assessed the loss at Rs. 31,500 net of excess clause. Aninvestigator appointed to ascertain the genuineness of claim concluded that the claim wasnot payable as the complainant had no insurable interest. The laptop was purchased byMrs. Vinita Aggarwal, complainant’s wife from Oxshott Consulting India Private Ltd. on22.4.2002, while the insurance cover was, however, in the name of Shri Salil Aggarwal.The claim was, therefore, repudiated vide letter dated 12.12.2003.FINDINGS : The laptop originally belonged to M/S Oxshott Consulting Private Ltd. wherethe complainant was employed as a Director. The company was wound up and the laptopwas sold to his wife Smt. Vinita Aggarwal. The laptop did not belong to him, but he was itsuser. He clarified this to the Development Officer who issued the covernote. He wasassured that the risk against loss or damage was covered for the user of the laptop. Hewas not aware of the policy limitations as the policy document was not issued to himdespite request. The insurer was advised by the legal counsel that mere possession oflaptop did not create an insurable interest for the claimant. As per terms and conditions ofAdhikari Suraksha Kavach Policy, the damage is indemnified only in respect of a laptopbelonging to insured and in his personal custody while anywhere in the world for purpose ofhis business or profession.DECISION : Held that having regard to the understanding given by the Development Officerin the matter of appropriateness of the policy, the fact that the policy was issued withoutverifying the question of ownership and insurable interest and that the terms and