3 After formal admission of the complaint, notice was issued to Opposite Parties and opposite party No. 1 appeared through counsel and filed written version and contested the complaint by interalia pleadings that the present complaint is not maintainable of law against the opposite party No.1. The present complaint is abuse the process of law and is not maintainable against the opposite party No.1. The bank has just assisted the complainant to get the insurance service from opposite party No.2 i.e. United India Insurance Compnay. The opposite party No. 1 is not having any other knowledge regarding the claim of the complainant. The complainant is having an account with the opposite party No.1 and is regular customer of the bank. The complainant has purchased insurance policy through replying opposite party, but the claim has been denied by opposite party No. 2 and 3 and OP No. 1 has no concern with the claim of complainant. The opposite party No. 1 has just assisted the complainant is getting the insurance policy. There is no deficiency on the part of the opposite party No.1. The opposite party No. 1 has denied the other contents of the complainant and prayed for dismissal of the same.
4 The opposite party No. 2 appeared through counsel and has filed written version by taking the preliminary objections that the complainant has filed a baseless, frivolous and an imaginary claim with an ulterior motive. The same is bad in law and cannot be entertained. The complainant has fabricated a false story with ulterior objectives to extract unlawful gains to which he is otherwise not entitled. The complainant is estopped by his own act and conduct to file the present complaint and the present complaint is not maintainable under law. The complainant does not fall within the ambit the consumer under section 2 of the CP Act. No cause of action has been arisen to the complainant to file the present complaint as the averments of the present complaint does not depict any consumer dispute between the parties. The complainant has not come to this Commission with clean hands and has suppressed the material facts form this Commission. The present complaint is a fit case where the commission shall take stringent action against the complainant as envisaged under section 26 of Consumer Protection Act, 1986 as amended upto date as the same is frivolous qua O.P. No. 2. The present complaint is in fact filed at the behest of certain vested interest, the purported complainant have filed present complaint out of the agreed and lust for the money and on account of the fact that the certain cases have gone adverse to various organizations though on different issues and that this complaint is alleged to be likely to meet the same rate. Opposite party No. 3 is acting as TPA for scrutinizing an processing of mediclaims for the mediclaim policies issued by the replying opposite party, the same are matter of record Insurance policies are always subject to its terms and conditions, which are having a legal binding force between the parties to the contract of insurance. The terms and conditions of the policy in question were duly supplied to the complainant alongwith the policy document and the said terms and conditions are the part and parcel of the insurance policy. Medical treatment taken by the complainant and thereafter the claim lodged by the complainant for the medical expenses insured by him for availing the said medical treatment is a matter of record. Sometimes the ailment of policy holder required further investigations after a preliminary checkup for knowing the exact cause of ailment and in those cases the cashless facility could not be provided unless and until the exact cause of ailment is not known to the insurer for that a continuous and regular information is required on the part of Hospital concerned. However, when the same has not provided by the Hospital Authorities, the replying opposite party is helpless to provide the cashless facility to the concerned policy holder. The said reimbursement claim has been duly scrutinized the processed by the opposite party No.3 after going through the medical treatment record of the complainant as provided by the complainant to opposite party No.3 and thereafter the claim of the complainant is rightly repudiated vide repudiation letter dated 18.05.2017 stating the reasons therein for such repudiation. The extract of said letter is reproduced hereunder for the kind perusal of this commission.
“ The present case for the treatment of Anil Sharma was admitted in Parvati Devi Hospital, from 29.04.2017- 01.05.2017 for OSA/CCF while scrutinizing the file, it is found that there is not active line of treatment given to the patient in view of congestive cardiac failure and hospitilization is done only for investigation purpose which could be done on OPD basis. Also patient was suffering from obstructive sleeve APNOEA which is due to obesity and patient is obese with BMI-41.2 as per clause 4.8 in policy any ailment due to obesity is not payable, hence the claim is not payable and stand repudiated.
“4.8 Convalescence, General debility, sun-down condition or rest cure, obesity treatment and its complications including morbid obesity, congenital external disease/ defects or anomalies, treatment relating to all psychiatric and psychosomatic disorder, infertility, sterility, venereal diseases, intentional self injury and use of intoxication drugs/ alcohol
The opposite party no. 1 stated that insurance is subject to terms and conditions of the policy and the same are having legal binding force between the parties to the contract of insurance and if there is any violation of terms and conditions, then the claim has to be decided accordingly. Keeping in view of aforesaid provisions of terms and conditions of the policy in question, the claim of the complainant has been rightly repudiated vide repudiation letter dated 18.05.2017 written to the complainant by the replying opposite party stating the aforesaid reason for repudiation of claim therein. It is worthy to mention over here that inadvertently due to typographical mistake, the claim through which clause of terms and conditions, the same has been repudiated is written as 4.8 instead of correct clause No. 4.9 in the said repudiation letter. However the contents of clause of the terms and condition is correctly depicted in the said repudiation letter.
5 Notice was issued to the opposite party No. 3 and it was duly served but it opted not to come forward to contest the complaint and consequently, the opposite party No. 3 was proceeded against ex-parte
6 To prove his case, the complainant has tendered in evidence his affidavit Ex. CW1/A alongwith documents Ex. C-1 to Ex. C-14 and closed the evidence. On the other hands. Ld. counsel for the opposite party No. 1 tendered in evidence affidavit of Sanjeev Sajjan Chief Manager Ex. OP1/A and closed the evidence. Ld. counsel for the opposite party No. 2 tendered in evidence affidavit of Dilbag Singh authorized officer Ex. OP2/A, copy of insurance policy Ex. OP2/1, copy of terms and conditions of policy Ex. OP2/2, copy of repudiation letter Ex. OP2/3, copy of medical record alognwtih medical bills Ex. OP2/4 and closed the evidence.
7 We have heard the Ld. counsels for the complainant and opposite parties No. 1 and 2 have gone through the record on the file.
8 In the present complaint, The complainant purchased the insurance policy named Mahabank Swasthya Yojana bearing number 1622012016484100000138669 on dated 21st January 2016 and the same policy was renewed on 16th February 20 17, valid for a period of one year . The representative of the opposite party selling the said insurance policy had assured and allured the complainant that the hospitalization is free of cost under the term and condition of this side policy.
9 The complainant was suffering from chest pain and was previously being treated by Dr. Sanjeev Arora at Deepak clinic Chownk Katra Karam Singh, Amritsar. On dated 29.04.2017 was admitted in Smt. Parvati Devi Hospital ,A Block , Ranjit Avenue , Amritsar and was diagnosed for Diastolic Dysfunction Grade II presented CHF and the findings of the Echocardiography report of the complainant showed stage 2LV Diastolic Dysfunction resting global LVEF 63% and was duly discharged by the doctor on 01.05.2017. However, the OP had not forwarded the approval of cashless facility of the complainant and hence the complainant was left with no other alternative but to pay the bills of hospitalization medicines and diagnostic tests.
10 Later, the complainant visited /contact the Ops number of time to settle the claim but Ops verbally informed the complainant that the claim of the complainant has been repudiated , when the complainant demanded the claim repudiation letter in writing they refused to provide the same and on repeated asking OPs gave email id 11 OP No 1 stated in its written version that the opposite party 1 , has just assisted the complainant to get the insurance service from opposite party number 2 that is united India insurance company the opposite party number one is not having any other knowledge regarding the claim of the complainant. There is no deficiency on the part of the opposite party No.1.
12 OP No. 2 stated in their written version that in the present case of reimbursement of Anil Sharma is that complainant was admitted in parvati Devi hospital from 29th April 2017 to 1st may 2017 for OSA / CCF while scrutinizing the file it is found that there is not active line of treatment given to the patient in view of congestive cardiac failure and hospitalization is done only for investigation purpose which could be done on OPD basis. Also patient is suffering from obstructive sleep Apnoea which is due to obesity and patient is obese with BMI 41.2 as per clause 4.8 in policy any alignment due to obesity is not payable hence the claim is not payable and stands repudiated.
“4.8 convalescence, general debility, run down condition or rest cure, obesity treatment and its complications including morbid obesity, congenital external disease or defects or anomalies, Treatment relating to all psychiatrist and psychologist disorders, infertility, sterility, venereal diseases, intentional self injury and use of intoxication drugs alcohols.”
13 As per opposite party the claim has been rightly repudiated vide reputation letter dated 18th may 2017 written to the complainant by the replying opposite party stating the foresaid reason for reputation of claim there in. It is worthy to mention over here that inadvertently due to typographical mistake the claim through which clause of term and conditions the same has been repudiated is written as 4.8 instead of correct clause number 4.9 in this side repudiation letter.
14 There is nothing on the file to show the claim of the complainant is based on fraud, misrepresentation and concealment. The complainant has placed on the file the medical treatment record of the hospital. There is nothing on the record to disbelieve the treatment record of the complainant. Now , let’s discuss whether there is negligence/ deficiency in service and unfair trade practice on part of the Ops .
- Ops repudiated the claim , stated that “ it is found that there is not active line of treatment given to the patient in view of congestive cardiac failure and hospitalization is done only for investigation purpose which could be done on OPD basis.” (Ex.c2) but Ops had not submitted any evidence to prove the same statement. Merely ,mentioned the line in the repudiation letter without any evidence or any doctor certificate or affidavit Ops are no body to judge what would be the line of treatment patient is required , it is the duty of the hospital /doctor to examine the patient on OPD basis or while hospitalized the same. Hence ,there is negligence/deficiency in service and unfair trade practice on part of the Ops .
- Ops repudiated the claim stated that “as per clause 4.8 in policy any aliment due to obesity is not payable” (Ex.c 2) but same clause 4.8 in policy terms and conditions stated that – dental treatment or surgery of any kind unless necessitated by accident and requiring hospitalisation ” (Ex.c 9) . Which clearly prove that Ops are failed to resolve the genuine grievance of the complainant which is a deliberate act of the Ops . Ops are so much in rush to repudiate the claim of the complainant that they mentioned the clause totally against the complainant treatment. There is deficiency in service and unfair trade practice on part of the Ops that after number of reminders by mail from the complainant they again send the same mail on dated 05/07/2017 (Ex.c4) mentioned the same wrong clause in the mail sent earlier on dated 21/06/2017. However , OP2 stated in their written version that it was a typographical mistake but it is the matter of negligent, irresponsible and wrongful behaviour of the OP and merely ,OP was only interested in repudiating the claim under any ground.
- The claim of the complainant has been repudiated by the TPA. However, no independent decision has been taken by the OP on the report given by the TPA, rather the OP has accepted the report of the TPA as it is. Further , OP No.3 failed to submit any report or affidavit to prove their point .
It is has been held by this commission in first Appeal No. 1105 of 2014 decided on 25.04.2017 “sukhdev Singh nagpal Vs New Karaian Pehalwal cooperative agriculture service society &others” that TPAs have no authority to reject the claim and such a power lies exclusively with the insurance companies. The TPA can only process the claim and forward the same to the insurance company and the competent authority of the insurance company is to decide about the same. The claim of the complainant was illegally and arbitrary rejected by the TPA, against the instructions of the IRDA. In view of this, it is common tendency of the insurance companies not to bring the true facts before the policy is issued to the notice of the insured person or the person, who is taking policy on his or her behalf.
- Op No.2 , placed on record (Ex. Op 2/3 ) as a repudiation letter on dated 18.05.2017. but failed to submit any postal receipt to prove that same had been send to the complainant .
- As per discharge summary and other tests reports (Ex. C10,C11,C12,C13 ) patient was diagnosed for Diastolic Dysfunction grade II presented CHF and the findings of the Echocardiography report of the complainant showed stage 2LV diastolic dysfunction resting global LVEF 63% due to which the doctor had advised the complainant to be admitted and conduct various tests. Further, ‘Morbid obesity is a serious disease that has been linked to shortened life expectancy ' , it is important to understand the difference between obesity which is only a common medical condition and morbid obesity - which is considered a disease.
15 Hence, It is crystal clear that the opposite parties in connivance with each other had firstly refused to provide cashless treatment to the complainant thereafter had harassed the complainant by delaying the matter on one pretext or the other and finally had wrongfully repudiate the claim of the complainant in an arbitrary and whimsical manner and had not even provided any cogent and possible justification thereof and further, not contact the doctor concerned who treated the complainant during the said hospitalization. O.Ps miserably failed to provide any evidence that stand to prove that they did any survey or appoint any doctor to examine the case in order to allow or repudiate the claim.
16 In view of the above discussion, the present complaint is allowed and the opposite party No. 2 is directed to make the payment of Rs. 37,794/- to the complainant. The complainant has also been harassed by the opposite party No. 2 for a long time, as such the complainant is also entitled to Rs. 5,000/- as compensation on account of harassment and mental agony and Rs 3,500/- as litigation expenses. Opposite Party No. 2 is directed to comply with the order within one month from the date of receipt of copy of the order, failing which the complainant is entitled to interest @ 9% per annum, on the awarded amount, from the date of filing the present complaint till its realisation. The present complaint against the opposite parties No. 1 and 3 is dismissed. Copy of order be supplied by the District Consumer Disputes Redressal Commission, Amritsar as per rules. File be sent back to the District Consumer Disputes Redressal Commission, Amritsar.
Announced in Open Commission
24.11.2022
