Haryana

Ambala

CC/445/2017

Paramjeet Kaur - Complainant(s)

Versus

Axis Bank Ltd - Opp.Party(s)

Yadwinder Gupta

26 Oct 2018

ORDER

 

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AMBALA

 

                                                          Complaint case no.        :  445 of 2018

                                                          Date of Institution         :  15.12.2017

                                                          Date of decision    :  26.10.2018

 

 

Paramjeet Kaur aged 55 years wife of Subeg Singh, R/o house no. 31, Village Tiwana, District Patiala-Punjab

  ……. Complainant.

 

 

1.  Axis Bank Limited, branch Ismailpur, District Ambala.

2.  Sukhwinder Singh son of Mangat Ram-Lamberdar, Village Balana, District Ambala.

3.  Tata AIG General Insurance Company ltd. Branch Office SCO-232, 234, Sector-34, Chandigarh

 

 ….…. Opposite Parties.

 

Before:        Sh. D.N.Arora, President.

                   Sh. Pushpender Kumar, Member.

 

 

Present:        Sh. Yadwinder Gupta, counsel for complainant.

 Sh. Rahul Vig, counsel for OP No.1.

 Sh. Bhajan Singh, counsel for OP No.2.

 Sh. Mohinder Bindal, counsel for OP No.3.

 

 

ORDER:

                   In nutshell, brief facts of the present complaint is that the complainant had purchased the Medi Prime Policy for one year valid period which commenced from 20.10.2015 to 19.10.206.  The complainant received a renewal notice from Sh. Atri Chakraborty, Senior Vice President-Operations and Systems claiming that policy of present complainant is expiring on 19.10.2016.  On the advice of Ops No.1 & 2 the complainant deposited premium amount for renewal of policy Rs. 13696/-with OP No.1. The OP No.1 issued payments acknowledgment slip dated 10.10.2016 to the complainant. The policy was effective on 20.10.2016 up to 19.10.2017.  As per Medi Prime Policy, the complainant was entitled to medical benefits. There was pain in knee of the complainant, matter was brought to the notice of Ops No. 1 & 2, the Ops No.1 & 2 directed to him to approach Fortis Hospital at Mohali. The complainant visited on 01.05.2017 at Fortis Hospital at Mohali on that day x-rays were performed against the payment of Rs. 990/- The doctors examined X-rays of the complainant, he was admitted in the hospital on 2.5.17 and was discharged on 8.5.17. The doctors performed total knee replacement (Bi-lateral) on 2.5.17. The amount of medical treatment under the circumstances Rs. 341966/- was deposited by the complainant. He further purchased the medicines of Rs. 1262/- vide receipt dated 22.5.17.  The complainant approached OP Nos. 1 & 2 and on their demand submitted bills etc. The OP Nos. 1 & 2 informed that claim of complainant has been for forwarded to the OP No.3 vide claim number1005571 and other payments of bills total Rs. 2252/- shall be reimbursed to the complainant. The complainant in routine on demand of OP Nos. 1 & 2 has latestly deposited renewal fee vide payment acknowledgment slip dated 11.6.2017 issued by OP No.1. The Ops has issued latest policy to the complainant but they had failed to process genuine health claim within the assured period, there is delay in the matter hence there is clear deficiency in service on the part of Ops.  Hence, the present complaint.

2.               Upon notice, OP No.1 appeared through counsel and tendered written statement raising preliminary objections qua complaint is not maintainable, locus standi, and non joinder and misjonder. On merits, OP No.1 stated that the payment of the premium amount by the complainant is not denied. It is submitted that proper receipt was issued for the payment received from the complainant. It is wrong and incorrect that the OP No.1 issued the policy to the complainant. The amount of premium received from the complainant was credited to the account of the OP no.3 as per the instructions of the complainant.  The amount of policy, terms and conditions, contract etc. is in between the complainant & OP No.3.

Upon notice, OP No.2 appeared through counsel and filed the written statement  and stated that the complainant has concealed the name of the close relative intentionally and not  implead  them as a party who are stated  to have taken  the complainant  to the bank  and the OP has nothing  to do with the policy  of complainant or her husband, as  the OP joined the OP No.3 on 22.9.2016 whereas the allegation pertain  to the year 2015.

Upon notice, OP No.3 appeared through counsel and tendered written statement  and stated that as a matter of fact  the claim of the complainant  against the  treatment of complainant in Fortis  Hospital, Chandigarh from 02.05.2017 to 08.5.2017, was duly entertained  in due course  and the entire   case  with all set of papers  was duly gone  through  by the qualified  team of doctors i.e. M/s Family Health Plan Insurance TPA Ltd. who is duly authorized  representative  of the OP no.3 in this  regard  to deal with. It is relevant  to mention here that the entire  claims under the Health Insurance  Policies  are being  entertained  and processed by this independent  and IRDA approved  agency consisting  of medical experts  on behalf of the Tata AIG General Insurance Company Ltd. that has been authorized  to deal with such claims  independently  and payments  are made  only as per their approval, recommendations and assessment and also bound with  their denial  of any claim. It is not out of place to mention here that the entire mediclaims are independently being processed and approved by such TPA companies on behalf of all the insurance companies being team of specialized doctors to deal with such claims. In the present case also, the request under the instant policy was received by the TPA from Fortis Hospital directly for confirmation of policy and a claim was also lodged with them. Since  it was the IInd year of the Health Insurance policy  wherein  as per Section 3 Clause C of the policy terms, the replacement done for Osteoarthritis  knee  joint is excluded for initial two years of Mediprime  policy  which thus falls under exclusion  and are not payable  so the said claim  was denied  and rejected. Section 3 Clause  C of the policy terms being part of the  said policy which deals with waiting  periods & coverage  of the insurance policy clearly and specifically  says that the illness  and treatments listed  therein  will be covered subject to waiting  period of 2 years  as long as the third policy year the insured  person  has been insured  under an Mediprime Policy  continuously  and without  break thus since  the treatment of complainant  for Bilateral Knee replacement  was done for Osteoarthritis  knee joint  and she was enrolled  in IInd year of Mediprime policy  so her this treatment was excluded  for initial two policy  years and the complainant  was duly informed  about the fate of her claim vide letter dated 28.7.2017. So, there is no deficiency on the part of the Ops and prayed for dismissed the present complaint.

3.                To prove his version complainant tendered his affidavit as Annexure C-A along with documents as annexure C-1 and C-7 and close her evidence. On the other hand, Counsel for the OP No.2 tendered affidavit as Annexure R-A/2 and closed their evidence.  Counsel for OP No.1 has tendered affidavit as Annexure R/A and closed their evidence.  Counsel for OP No.3 has tendered as Annexure R-X alongwith document as Annexure R-1  & R-2 and close their evidence.

4.                We have heard both the counsels of the parties and carefully gone through the case file.

5.                Admittedly the complainant  had obtained the medical policy for  the period of one year which was valid from  20.10.2015 upto 19.10.2016 and paid the premium amount vide Annexure C-1 and after expiry of that period he obtained the policy for next year which was valid  from 20.10.2016 up to 19.10.2017 and he paid the premium as per Annexure C-2. As per the version of the complainant there was a pain in the knee and he approached to the Fortis Hospital on 01.05.2017 and he was admitted in the hospital on 02.05.2017, necessary investigation got done like X-ray etc. and he was advised for Left Total knee replacement. After consent, clearance, PAC, Patient was taken up total knee replacement (bilateral) on same day which is evident from Annexure C-4 i.e. discharge summary and he was discharged on 11.05.2017 and hospital has issued the bill of Rs. 3,41,966/- as per Annexure C-5. The complainant has claimed the above said amount of treatment as per policy but OP repudiated the claim as per Section 3 exclusion, Sub Clause 3 which is reproduce as under :-

“However, a waiting period of two years will not apply if the insured person was insured continuously and without interruption for atleast two years under any retail health insurance policy of an Indian Non-Life Insurance Company”.

The complainant has also admitted the above said clause in the affidavit submitted by the complainant as per Annexure C-A.

6.                We have gone through the above said clause, Section 3 Sub clause C of the policy terms, replacement done for  Osteoarthritis  knee  joint is excluded for initial two years of Mediprime  policy  which thus falls under exclusion  clause and expensed incurred on the treatment are not payable. In the present case, the complainant has obtained the medical policy for one year i.e. 20.10.2015 to 19.10.2016 and he renewal his above said policy for next year for the period  20.10.2016  to 19.10.2017 and the complainant has taken the  treatment from the Fortis hospital and knee has been replacement within two years i.e. 02.05.2017. In this way, the complainant has not completed of two years continue policy as per terms and conditions of the policy. So in view of the above facts, it is clear that the complainant is not entitled the medical claim. Although, the complainant has also produced the Annexure C-3 taking the third year policy and paid the amount Rs. 17,750/- on 11.06.2017 but the complainant has cleverly deposit the above said amount before completion of two years whenever the complainant has taken the treatment on 2.5.2017 and the above deposition of the third year policy does not helpful to the complainant. Therefore, the case of the complainant covered under the exclusion Section 3 Sub Clause C of the policy. We do not find any deficiency in service on the part of Ops. Thus, the complainant is not entitled any relief. Hence, the present complaint is liable to be dismissed and same is hereby dismissed with no order as to cost. Copy of this order be supplied to both the parties free of cost. File be consigned to record room after due compliance.

Announced on : 26.10.2018

 

 

 

                   (Pushpender Kumar )                        (D.N. ARORA)

                                   Member                                          President