Punjab

Ludhiana

CC/14/117

Bhushan Kumar - Complainant(s)

Versus

Cholamandalam MS Gen.Ins.Co.Ltd - Opp.Party(s)

28 Jan 2015

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, LUDHIANA.

 

       C.C. No: 117 of 28.01.2014

                                                                      Date of Decision:28.01.2015

 

Bhushan Kumar Aggarwal son of Shri Hans Raj, B-XXXIV-1487, Street No.7, Near PSEB Office, New Chandan Nagar, Haibowal Kalan, Ludhiana-141001.

……Complainant

                                                    Versus          

1.Cholamandalam Ms General Insurance Co.Ltd., having registered office at Dare House, 2^nd Floor, 2 NSC Bose Road, Chennai-600001, Tamil Nadu  through its Managing Director.

2.Cholamandalam Ms General Insurance Co.Ltd., 132/3, FF, KL Plaza, Rani Jhansi Road, Ludhiana-141001, through Manager.

3.Indusind Bank Limited, Miller Ganj Branch, Miller Ganj, Ludhiana-141003 through the Chief Manager.

                                                                             ……...Opposite Parties

        Complaint under section 12 of the Consumer Protection Act,1986.        

 

Quorum:     Sh.R.L.Ahuja, President.                 

                   Sh.Sat Paul Garg, Member.

                 

Present:       Sh.R.K.Nayyar, Adv. for complainant.

Sh.Vyom Bansal, Adv. for Op1 and OP2.

OP3 ex-parte.

                            

ORDER

 

R.L.AHUJA, PRESIDENT

 

1.                Complainant Sh.Bhushan Kumar Aggarwal, has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 (herein-after in short to be described as ‘Act’) against Cholamandalam Ms General Insurance Co.Ltd., having registered office at Dare House, 2^nd Floor, 2 NSC Bose Road, Chennai, Tamil Nadu  through its Managing Director and others(herein-after in short to be described as ‘Ops’)- directing them to pay Rs.4,34,168/- i.e. the amount spent on investigation and treatment at Hero DMC Heart Institute as per bill No.66708 dated 22.8.2012 to the complainant alongwith interest @18% on the aforesaid amount from the date of aforesaid  bill till actual payment besides Rs.50,000/- as compensation and Rs.15,000/- as litigation expenses and other benefits to the complainant.

2.                In brief, the case of the complainant is that the OP3 approached the complainant at Ludhiana for Medical insurance under their Group Master Policy, Indus Family Health-Gold Plan and the complainant agreed to subscribe to said policy and paid Rs.10,000/- as premium towards the aforementioned policy. OP1 issued Certificate of Insurance dated 2.4.2012, No.IBL-Gold-004793 for one year from 22.3.2012 to 21.3.2013 besides giving therein other details and particulars of Group Master Policy, Indus Family Health-Gold Plan, covering the complainant and his wife Ms.Kiran Aggarwal. On or about 29^th July, 2012, the complainant felt uncomfortable and consulted Hero DMC Heart Institute, A Unit of Dayanand Medical College & Hospital and was advised to get himself admitted for thorough check up and investigation. Complainant got himself admitted under Admission NO.66295 and CR No.154644 on 2.8.2012 and CAG was done and it was diagnosed that complainant was having Diabetes Mellitus Type II with CAD with Triple Vessel Disease which required surgery. After carrying out various investigations and tests, surgery was performed on 7.8.2012 and complainant was discharged on 22.8.2012. Complainant filed claim vide ‘Chola MS Help-Health Claim Form’ dated 26.8.2012, duly filled in for reimbursement of medical expenses incurred on treatment enclosing therewith all the original documents, namely discharge summary card, bill No.66708 dated 22.8.2012 to OP1. The complainant received letter, Ref A5449610A dated 27.9.2012 from Corporate office of OP1 informing the complainant for rejection of claim for reimbursement of medical expenses being inadmissible. Such rejection of claim for reimbursement of medical expenses on the ground of pre-existing illness/disease is claimed to be illegal, unlawful, arbitrary, malafide and against the principles of natural justice and is without application of mind or supported by any actual investigation, enquiry and medical opinion of doctors specialist in this field. Hence, this complaint.

3.                Upon notice of the complaint, Op1 and OP2 were duly served and appeared through their counsel Sh.Vyom Bansal, Advocate and filed their written reply, whereas, notice of the complaint was sent to OP3 through registered post on 26.03.2014, but the same was not received back and as such, after expiry of 30 days of period, Op3 was proceeded against ex-parte vide order dt.28.4.2014 by this Forum. 

4.                OP1 and OP2 in their written reply took up certain preliminary objections that the present complaint in any form is not maintainable before this Hon’ble Forum as no cause of action arose within the territorial jurisdiction of this Hon’ble Forum and the complainant has miserably failed to establish the territorial jurisdiction of this Hon’ble Forum; the complainant has not approached this Hon’ble Forum with clean hands and is guilty of suppression of material facts as the sole motive of the complainant is to extort illegal and unjust money from the answering Ops neither payable nor due to the complainant and the claim of the complainant has been denied for violation of the terms of the policy and jurisdiction of this Hon’ble Forum to try and decide the present complaint. Further, it has been submitted that the complainant and his family was insured for health cover of a maximum of Rs.4 lakh vide policy No.HWT-00004567-000-00 for the period of 22.3.2012 till 21.3.2013. Upon the receipt of the health claim form dated 26.8.2012 from the complainant and upon the receipt of the medical documents, the insurance company referred the matter to its panel Health India Medical Services Pvt. Ltd.(TPA) for investigation and opinion. The said TPA verified the treatment and investigated the matter and recorded the statement of complainant and his family physician. After scrutinized the documents and application of mind, it was noted that the complainant was having history of Diabetes Mellitus for the past 7-8 years and was on Tab. Dutrol 500 mg and was patient of hypertension for the past 2 years. The complainant had concealed the said facts in his proposal form despite having full knowledge of such ailment. Complainant should have disclosed the same at the time of obtaining the insurance policy. Since the hospitalization and treatment was for the management of pre-existing disease and their complications, it was not maintainable and fell under the exclusion clause of the medical policy. On the basis of this, the insurance company rightly repudiated the claim after application of mind by its officials/competent authority. Hence, the claim was rightly repudiated by answering Ops vide its letter dated 27.9.2012 for the reason of the claim being inadmissible as per General exclusion clause C-1 of the policy. The complainant had concealed the fact about his existing disease while taking the present policy and has not filed the true information in the proposal form. On merits, similar pleas were taken as mentioned in the preliminary objections and at the end, denying any deficiency in service on the part of the answering Ops and denying all other allegations levelled by the complainant in his complaint against the answering OPs, answering OPs made prayer for dismissal of the complaint with costs.

5.                In order to prove the case of the complainant, learned counsel for the complainant tendered into evidence affidavit of complainant as Ex.CA in which, he has reiterated all the allegations made by him in the complaint and Further, learned counsel for the complainant has proved on record the documents Ex.C1 to Ex.C8.

6.                On the other hand, in order to rebut the case of the complainant, learned counsel for the OP1 and Op2 adduced evidence by placing on record affidavit Ex.RA of Sh.Ashutosh Kumar, its Assistant Manager Claims(Legal), in which, he has reiterated all the contents of reply filed by OP1 and Op2 and refuted the case of the complainant. Further, learned counsel for the Op1 and Op2 has relied upon documents Ex.R1 to Ex.R7.

7.                We have heard the learned counsel for the parties and have also perused the record on the file very carefully.

8.                Perusal of the record reveals that it is an undisputed fact that the complainant had purchased the policy in question which was valid for the period from 22.3.2012 to 21.3.2013 on payment of premium covering the complainant and his wife. It is further an undisputed fact that the complainant had felt uncomfortable and had consulted Hero DMC Heart Institute, A Unit of Dayanand Medical College & Hospital and was advised to get himself admitted for thorough check up and investigation. Complainant had got himself admitted under Admission No.66295 and CR No.154644 on 2.8.2012 and CAG was done and it was diagnosed that the complainant was having Diabetes Mellitus Type II with CAD with Triple Vessel Disease which required surgery. Further, it is an undisputed fact that after conducting various investigations and tests, the surgery of the complainant was performed on 7.8.2012 and the complainant was discharged on 22.8.2012 and the complainant had spent Rs.4,34,168/- qua his treatment which was paid by the complainant to the Hero DMC Heart Institute vide bill dated 22.8.2012. Further, it is an undisputed fact that due intimation was given to the Ops and the claim was lodged with them. However, the same was repudiated by the Ops vide their letter dated 27.9.2012 Ex.C5(Ex.R7) on the ground that the present ailment (Coronary artery disease/triple vessel disease) is a complication of diabetes which is existing since 6 years and hypertension since 2 years, which are prior to the inception of the policy (22.3.2012), hence, present ailment is considered as pre-existing disease and the claim is inadmissible as per General Clause C-1 which reads as “No indemnity is available or payable for claims directly or indirectly caused by, arising out of or connected to the following: 1)Any pre-existing condition benefits will not be payable for any condition(s) as defined in the policy, until 24 consecutive months of coverage for the insured person have elapsed, since inception of the first policy with the insurer.”

9.                Perusal of the evidence of the Op1 and OP2 reveals that they have furnished affidavit Ex.RA of Sh.Ashutosh Kumar, its Assistant Manager Claims(Legal), in which, he has deposed on the lines of the written reply filed by the OP1 and OP2. Further, evidence of OP1 and OP2 reveals that OP1 and OP2 have not placed on record any affidavit of the concerned doctor who examined the documents submitted by the complainant after his surgery and found his opinion that the present ailment (Coronary artery disease/triple vessel disease) is a complication of diabetes which is existing since 6 years and hypertension since 2 years, which are prior to the inception of the policy. Further, OP1 and OP2 have not placed on record any such evidence, from which, it could be presumed that the complainant was already suffered from the aforesaid disease prior to the inception of the insurance policy. Rather, it is proved from the record that earlier, though the complainant was suffering from Hypertension and diabetes but it cannot be presumed that ailment Coronary Artery Disease/Triple Vessel disease was the result of any complication of the diabetes or hypertension disease nor it has been so reported by the concerned doctor in the discharge summary Ex.C2 of the complainant or in the medical certificate Ex.C7 issued by the doctor. So, it appears that Ops have arbitrarily and illegally repudiated the claim of the complainant on the ground of pre-existing disease and as such, the repudiation of the claim of the complainant is not sustainable and is liable to be quashed.

10.              In view of the above discussion, we hereby allow this complaint and as a result, hereby quash the repudiation letter dated 27.9.2012 Ex.C1 (Ex.R7) issued by the Ops to the complainant and further, we direct the Ops to settle and pay the claim of the complainant as per the terms and conditions of the insurance policy in accordance with law and further, Ops are directed to pay compensation to the tune of Rs.20,000/-(Twenty thousand only) on account of mental pain, agony and harassment suffered by the complainant and Rs.2000/-(Two thousand only) as litigation costs to the complainant. Compliance of order be made within 30 days from the date of receipt of copy of this order, failing which, Ops shall be liable to pay interest @9% from the date of lodging of claim till its realization. Copies of the order be sent to the parties free of cost and thereafter, file be consigned to the record room.

 

                             (Sat Paul Garg)              (R.L.Ahuja)

                               Member                       President.   

Announced in Open Forum

Dated:28.01.2015

Gurpreet Sharma.