Chandigarh

DF-II

CC/472/2016

Davinder Kumar - Complainant(s)

Versus

Branch Manager, Syndicate Bank - Opp.Party(s)

Saurav Goyal Adv.

03 Nov 2017

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH

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Consumer Complaint  No	:	472 of 2016
Date  of  Institution	:	06.07.2016
Date   of   Decision	:	03.11.2017

 

 

 

 

Davinder Kumar son of Sh.Chaman Lal, resident of H.No.G-3, Near Railway Station, Nilokheri, District Karnal

                               …..Complainant

Versus

1]  Branch Manager, Syndicate Bank, Branch Office Committee Chowk, Karnal, Haryana.

2]  Divisional Manager, United India Insurance Co. Ltd., D.O.-II, SCO No.177-178,   Sector 8-C, Chandigarh.

3]  Manager, Med Save Healthcare (TPA) Ltd., SCO 121-123, 2^nd Floor, Sector 34-A, Chandigarh.

                      ….. Opposite Parties

BEFORE:  SH.RAJAN DEWAN                 PRESIDENT

         MRS.PRITI MALHOTRA             MEMBER

                                SH.RAVINDER SINGH              MEMBER

                               

Argued by :    

Sh.Saurav Goyal, Adv. for complainant.

OP No.1 exparte.

Sh.G.D.Gupta, Adv. for OPs No.2 & 3.

 

  

PER PRITI MALHOTRA, MEMBER

 

 

          Briefly stated, the complainant purchased Mediclaim policy through OP No.1 Bank, being its account holder, from OPs No.2 & 3 for a sum assured of Rs.5.00 lacs for the period from 14.10.2013 to 13.10.2014 (Ann.C-1 & C-2) thereby covering the complainant and his family members.  It is averred that at the time of availing the said Mediclaim insurance policy, the complainant and his family members were in perfect state of health.  It is averred that on 2.12.2013, when the complainant was at his sister’s house at Chandigarh, he suddenly felt uneasiness and as such was taken to Fortis Hospital, Mohali, where the doctor, after giving first aid, advised him to come on 3.12.2013 for further check-up. It is submitted that on 3.12.2013, Eco and other tests were done by the doctors at Fortis Hospital, Mohali and after getting its report, the Doctor advised him to immediately go for Aortic Valve Replacement (AVR).  It is submitted that the complainant approached OPs No.2 & 3 for cashless facility for the said treatment, but Opposite Party No.3 vide letter dated 4.12.2013 denied that claim is on the ground of preexisting nature of illness (Ann.C-3). The complainant was discharged on 12.12.2013 from Fortis Hospital, Mohali, where he had to pay the whole medical expenses of Rs.2,44,520/- (Ann.C-4 & C-5).  Thereafter, the complainant lodged a claim for reimbursement of the medical expenses with the OPs No.2 & 3 and also clarified all the queries raised by them and also explained that this was his first hospitalization and therefore, no previous hospital record of the complainant was available and also submitted certificate of the treating doctor (Ann.C-10 & C-11).  However, the OPs NO.2 & 3 did not settle the claim of the complainant, rather refused it.  Hence, this complaint has been filed alleging the above act of the OPs NO.2 & 3 as deficiency in service and unfair trade practice. 

 

2]       The Opposite Party No.1 did not turn up despite service of notice sent through regd. post on 13.7.2016, hence it was proceeded exparte vide order dated 16.8.2016. 

 

         The Opposite Parties No.2 & 3 have filed joint reply and while admitting the factual matrix of the case, stated that the complainant has been suffering from Calcific Aortic Stenosis (PSG-74 MMhg) since long and for which he underwent Aortic Valve Replacement (AVR) on 4.12.2013 in Fortis Hospital.  It is stated that the complainant has been taking medicine actively since 2013 and the complainant did not disclose these facts in the proposal form while seeking insurance cover and suppressed the material information and hence not covered under the policy.  It is submitted that the complainant was given due opportunity to provide the complete facts/details and information about the inception & duration of the disease vide letter dated 19.5.2014, which was not satisfactorily replied.  However, keeping in view the entire circumstances and medical record of the complainant, the claim of the complainant was declined by TPA vide email/letter dated 24.9.2014. It is pleaded that since the present ailment was a pre-existing disease under the terms & conditions of the policy, therefore, the claim was repudiated by the insurer due to non-compliance and submission of information and documents. Pleading no deficiency in service and denying rest of the allegations, it is prayed that the complaint be dismissed.

 

3]       Parties led evidence in support of their contentions.

 

4]       We have heard the ld.Counsel for the parties and have also perused the entire record.

 

5]       The record on filed establishes that the complainant in the present complaint has thoroughly been harassed at the hands of Opposite Parties No.2 & 3, who in order to avoid the payment of the medical claim, claimed under the Mediclaim policy in question, kept him engaged in procuring one document or the other and ultimately, closed his claim as ‘No Claim’. 

 

6]       In the given case, the OPs No.2 & 3 have not acted fairly and also not followed the guidelines issued by their Apex body i.e. IRDA (Insurance Regulatory and Development Authority), from time to time, whereby while deciding the fate of the claim, the Insurance Company is bound to call for the documents from the insured in one go and not in piecemeals i.e. one after the another as had been done by the OPs NO.2 & 3 in the present case.  

 

7]       The evidence put forth by the complainant on the file genuinely established that the complainant had supplied all relevant documents, as were demanded by the OP Insurance Company and also well explained the non-supply of the documents/information, as demanded by them. 

 

8]       The letter/email dated 23.9.2014 of Opposite Parties NO.2 & 3 (Ann.C-15) shows that the claim of the complainant has been closed as ‘No Claim’ for non-submission of the documents, mentioned in the said email.  The perusal of this email reveals that many a documents claimed to have been demanded from the complainant have not even been mentioned in the earlier e-mails sent by the OPs No.2 & 3 to the complainant.  It is a proven fact that the complainant duly provided the Treating Doctor’s Certificate to the OPs NO.2 & 3 dated April 25, 2014 (Ann.C-11), whereby it has categorically been mentioned that :-

“This is in reference to your clarification of Mr.Devinder Kumar, aged 43 years, Policy No:110300/48/13/14/00000901.

 

Patient presented with complaint of difficulty in breathing (off & on) since 5-7 days.  As stated by the patient there is no history of similar complaint in the past.  His echocardiography was done which showed calcific aortic stenosis (PSG-74mmHg). For which he underwent Aortic Valve Replacement (AVR) on December 4, 2013.”      

 

9]       Record reveals that in order to satisfy the queries of the OPs No.2 & 3 the complainant sent another Certificate issued by the same treating doctor dated October 24, 2014 (Annexure C-17), which mentions as under:-

 

“This is in reference to your clarification of Mr.Devinder Kumar, aged 43 years, Policy No.:110300/48/13/14/ 00000901.

 

As reply has already been given in previous letter on dated April 25, 2014, patient presented with complaint of difficulty in breathing (off & on) since 5-7 days. As stated by the patient there is no history of similar complaint in the past.  His echocardiography was done which showed calcific aortic stenosis (PSG-74mmHg). For which he underwent Aortic Valve Replacement (AVR) on December 4, 2013”

 

10]      The above certificates issued by the Treating Doctor, are quite sufficient to establish that the complainant was not having any pre-existing disease, as alleged by the OPs No.2 & 3 and was not having any past history of any illness.  Thus, the denial of cashless treatment as well as the denial of reimbursement of the claim filed by the complainant, both on the ground of pre-existing disease is totally illegal, unjustified and amounts to deficiency in service on their part.

 

11]      From the discussion above, the deficiency in service on the part of Opposite Party No.2 & 3 has been proved. Therefore, the complaint is allowed against Opposite Party No.2 & 3 and dismissed qua Opposite Party NO.1. The Opposite party No.2 & 3 are directed as under:-

1. To reimburse an amount of Rs.2,47,749/- to the complainant (the medical expenses incurred by the him on the treatment during the policy cover), along with interest @9% p.a. from the date of repudiation i.e. 23.9.2014 till its actual payment;

 

2. To pay Rs.15,000/- as compensation for the harassment suffered by the complainant on account of deficient service;

 

3. To pay litigation expenses to the tune of Rs.7,000/-.

 

         This order shall be complied with by Opposite Party No.2 & 3 within a period of 30 days from the date of receipt of copy of this order, failing which they shall also be liable to pay interest @9% per annum on amount of compensation from the date of filing this complaint till realization, apart from complying with direction as at sub-para (a) & (c) above.

 

12]      However, the complaint qua Opposite Party NO.1 stands dismissed.

        Certified copy of this order be communicated to the parties, free of charge. After compliance file be consigned to record room.

Announced

3^rd November, 2017                                                                Sd/-

                                                                   (RAJAN DEWAN)

PRESIDENT

 

 

                                                Sd/-

 (PRITI MALHOTRA)

MEMBER

 

Sd/-

(RAVINDER SINGH)

MEMBER