Before the District Consumer Disputes Redressal Forum, Rohtak.
Complaint No. : 337
Instituted on : 07.06.2017
Decided on : 30.07.2019.
Krishan Kumar Chawla Age 67 years s/o Sh. Ishwar Chand R/o H.No.100/8(203 ward No.32) Shivaji colony, Rohtak.
.......................Complainant.
Vs.
- United India Insurance Company Ltd. 24 Whites Road Chennai 600014 through its manager/chairman/managing director.
- Branch Manager, Andhra Bank HUDA Complex, Rohtak.
- Good Health TPA services limited, Plot no.49 nagarjuna hills punjagutta, Hyderabad 500082.(through its Manager/MD/Chairman).
……….Opposite parties.
COMPLAINT U/S 12 OF CONSUMER PROTECTION ACT,1986.
BEFORE: SH.NAGENDER SINGH KADIAN, PRESIDENT.
SH. VED PAL, MEMBER.
DR. RENU CHAUDHARY, MEMBER.
Present: Sh.Kamal Gagneja, Advocate for the complainant.
Sh.D.N.Singhal, Advocate for opposite party No.1.
Opposite party No.2 & 3 exparte.
ORDER
NAGENDER SINGH KADIAN, PRESIDENT:
1. Brief facts of the case are that on 15.07.2014 complainant had insured himself & his wife with the respondents by taking a mediclaim policy vide policy No.0504002816P10366002. That respondent no.2 is an authorized bank for respondent no.1 and complainant paid premium to respondent no.2 well within time and the policy was renewed in the year 2015-16 & 2016-17. That on 27.07.2016, wife of the complainant fell ill and she got treatment from Dr. Lalita Marwah. That on 05.08.2016, Dr. Lalita Marwah referred her to Rajiv Gandhi Cancer Institute for further treatment. That on 05.08.2016 the complainant visited the Rajiv Gandhi Cancer Institute, alongwith his wife and on 08.08.2016 some tests were done. That on 15.08.2016 wife of the complainant was admitted for surgery and timely intimation was given to insurance company and claim id 156138 generated by the respondent. That the wife of complainant was discharged on 19.08.2016 and remained under treatment from the alleged hospital till 31.08.2016 for which complainant had to spent Rs.303657/- as treatment expenses. That some mistake was done by the staff of hospital in the address and after rectification, the complainant sent all the bills on dated 01.09.2016 alongwith treatment record to the opposite party No.3 by DTDC courier vide receipt No.V32006723. That on 30.08.2016 Radiation therapy was advised for the patient and on 21.09.2016 wife of complainant was admitted at BLK Super specialty Hospital, New Delhi and the complainant spent an amount of Rs.67150/- as treatment charges. Respondents were duly intimated and claim form was submitted alongwith documents. But despite repeated requests of the complainant and legal notice dated 09.03.2017, claim amount has not been paid by the opposite parties till date. That the act of opposite parties is illegal and amounts to deficiency in service. Hence this complaint and the complainant has prayed for directing the opposite parties to pay the treatment expenses of Rs.370807/- alongwith interest @ 18% p.a. from the date of hospitalization till its realization, Rs.40000/- as compensation for mental harassment and Rs.35000/- as litigation expenses to the complainant explained in relief clause.
2 After registration of complaint, notice was issued to the opposite parties. Opposite party No.1 appeared and filed its written reply submitting therein that the complainant had deliberately concealed the history of illness. It is never possible that the symptoms were earlier not available or the patient earlier not visited any doctor for the said illness which was in an aggravating condition as a chronic medical case. Insured had failed to cooperate in declaring & sharing the history as also earlier medical examination of claimed illness/condition which has obviously developed over a long period with evident symptoms. Concealment of such facts is tantamount to breach of utmost good faith, non cooperation with Company’s claim settling representative-TPA and thus a breach of policy terms & conditions making the claim void and also is fraudulent as well. It is prayed that complaint may kindly be dismissed with costs. Notice sent to opposite party No.2 received back duly served and notice sent to opposite party no.3 through registered post not received back. As such, opposite party No.2 & 3 were proceeded against exparte vide order dated 27.07.2017 of this Forum.
3. Ld. counsel for the complainant in his evidence has tendered affidavit Ex.CW1/A, documents Ex.C1 to Ex.C82 and has closed his evidence on dated 22.10.2018. Ld. counsel for the opposite party No.1 has tendered affidavit Ex.RW1/A, documents Ex.R1 to Ex.R25 and has closed his evidence on dated 10.04.2019.
4. We have heard learned counsel for the parties and have gone through material aspects of the case very carefully. Written arguments also filed by ld. counsel for the opposite party No.1.
5. We have perused written statement field by the opposite party No.1, affidavit and written arguments. Some different facts have been mentioned in the written notes by the respondent no.1. In preliminary objections of the written statement filed by respondent no.1, it is submitted that the complaint is false and fabricated and not maintainable. The complaint is filed by the complainant after concealing the material facts and also suppressed the true facts. The respondent no.1 further submitted that complainant has mischievously misrepresented the case and withheld the factum of medical history and medical examination because there is a pre existing illness and that to confirm the same, the detailed investigation evidence and cross-examination is required. These facts could not be decided summarily, so the complainant should file a civil suit and the complaint is liable to be dismissed on this ground alone. On merits, the main stress of the respondent no.1 is that the complainant has a pre-existing illness and have past medical history. In written submission, the respondent no.1 also stressed that there is deficiency in service on the part of complainant because the TPA have wrote so many letters to the complainant and respodnentno.2 for supplying the documents and to clarify the queries raised by the TPA of respondent no.1. The respondent no.1 further contended that the complainant was operated only for hysterectomy and as per terms and conditions of the policy, his claim is restricted upto 20% of the sum insured subject to maximum of Rs.50000/-.
6. We have perused all the relevant documents placed on record by both the parties. No doubt, the respondent No.3 Good Healh TPA Services Ltd. have wrote so many letters to the complainant but the complainant has placed on record so many letters i.e. courier receipts Ex.C47 and Ex.C55 and established that he had already sent all the required documents and clarifications to the respondent no.3 as and when they demanded the same. The perusal of the Ex.C46 itself shows that one of the courier weight was 490 gms and it was sent to the respondent no.3 on dated 0109.2016. Thereafter he also sent another courier in the month of November 2016. We have also perused the mail written by the respodnentno.3 on dated 22.02.2017, in which respondent no.3 admits that received request from the complainant. Respondent also wrote an another mail to the complainant on 22.02.2017 for supply of some documents which is Ex.C65. In response, the complainant wrote another mail to the respondent no.3 which is Ex.C67 and submitted that he had already deposited all the relevant documents and clarification with the company. Thereafter the complainant also gave a notice through his counsel on dated 09.03.2017 and a reply was also submitted by the TPA i.e resplendent no.3 which is Ex.C74. After that, the complainant also wrote a mail to the TPA Good Health Services Ltd. on dated 01.05.2017 and attached again all the relevant documents i.e. a clarification certificate issued by Rajiv Gandhi Cancer Institute and sent an affidavit and other documents. After receiving all the relevant and required documents, respondent officials has not released any claim amount to the complainant, which itself amounts to deficiency in service. The complainant counsel also argued on the point that the complainant is entitled to an amount of Rs.370807/- because the complainant’s wife was not treated only for hysterectomy but she was also operated for some another ailments. ‘We have perused Ex.C44, discharge summary issued by Rajiv Gandhi Cancer Institute and Research Centre. As per this document, the wife of the complainant was also diagnosed for Carcinoma Endomentrium and was operated for Robotic Radical Hysterectomy(TypeII) with B/L PLND + Omental Biopsy+ Fluid cytology under GA on 16.08.2016. Meaning thereby, the complainant’s wife was not only operated for Hysterectomy but was also operated for some other ailments as mentioned in Ex.C44. So the respondent no.1 has no limited liability on account of Hysterectomy, but the complainant is also entitled for whole claim on account of other ailments also.
7. Perusal of the documents shows that nothing was concealed by the complainant because the respondent officials failed to place on record any document that Mrs. Laj Chawla wife of the complainant was suffering earlier to the proposal for the policy. Moreover, the first insurance was purchased by the complainant in the year 2014 and thereafter the same was renewed by the respondent no.1 well within time. To prove this fact complainant has placed on record Ex.C83, an account statement. The perusal of this account statement shows that the policy was renewed well within time and premium amount was deducted from the account of complainant and same was transferred to respondent no.1 by the respondent no.2. One more fact has been cleared after perusal of this account statement that the complainant is an accountholder in the bank of respondent no.2 and a master policy i.e. Taylor made Group health policy was issued by the respondent no.1 for the account holder of the bank.
8. Perusal of the documents itself shows that the complainant’s wife is suffering from cancer and is entitled for claim under major surgeries not only minor surgeries. Complainant’s wife was operated in Rajiv Gandhi Cancer and Research Institute and she spent an amount of Rs.370000/- on her treatment but as per terms and conditions of the policy, he is only entitled for actual expenses incurred or 70% of the sum insured, whichever is less. In the present case, as per respondents the actual expenditure incurred by the complainant is Rs.370000/- and the sum assured is Rs.5 lacs and 70% of the sum assured comes to Rs.350000/- as such complainant is entitled for the alleged amount.
9. In view of the facts and circumstances of the case, complaint is allowed and we hereby direct the opposite party No.1 to pay a sum of Rs.350000/-(Rupees three lacs fifty thousand only) alongwith interest @ 9% p.a. from the date of filing the present complaint i.e. 07.06.2017 till its realization and shall also pay a sum of Rs.5000/-(Rupees five thousand only) as compensation on account of deficiency in service and Rs.5000/-(Rupees five thousand only) as litigation expenses to the complainant within one month from the date of decision.
10. Copy of this order be supplied to both the parties free of costs. File be consigned to the record room after due compliance.
Announced in open court:
30.07.2019.
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Nagender Singh Kadian, President
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Ved Pal Hooda, Member.
……………………………….
Renu Chaudhary, Member
