CONSUMER DISPUTES REDRESSAL COMMISSION – X
GOVERNMENT OF N.C.T. OF DELHI
Udyog Sadan, C – 22 & 23, Institutional Area
(Behind Qutub Hotel)
New Delhi – 110016
Case No.315/2011
- FORTIS HEALTHCARE (INDIA) LIMITED
A COMPANY INCORPORATED UNDER THE
COMPANIES ACT, 1956HAVINGITS
REGISTERED OFFICE AT
ESCORTS HEART INSTITUTE RESEARCH CENTRE,
OKHLA ROAD
NEW DELHI
- Ms. RUCHI MAHAJAN
D/o SHRI P.D. MAHAJAN
R/o F14/ 10, MODEL TOWN-2,
DELHI 110009 …..COMPLAINANTS
Vs.
- CHOLAMANDALAM MS GENERAL INSURANCECOMPANY LTD. NEAR GANDHI NAGAR MOD 1 TONK ROAD JAIPUR – 302015 (RAJ)
- PARAMOUNT HEALTH SERVICES PVT. LTD.
D-39, OKHLA INDUSTRIAL AREA, PHASE – 1,
NEW DELHI 110020.…..RESPONDENTS
Date of Institution-29.07.2011
Date of Order- 12.10.2022
O R D E R
MONIKA SRIVASTAVA – PRESIDENT
The complainant has filed the present complaint seeking a sum of Rs. 2,50,000/- towards the claim and Rs.5,00,000/- as compensation towards mental agony, harassment and further cost of Rs. 50,000/- as litigation cost along with interest at the rate of 24% per annum.
- The complainant here is Fortis healthcare India limited which has taken health insurance cover (hereinafter referred to as ‘policy’) from OP no.1 i.e insurer for its employees and their dependents including complainant no. 2.
- OP no.1 appointed OP no.2 i.e Paramount Health Services hereinafter referred to as TPA as its administrator for smooth administration and working.
- It is stated by the complainant that huge amount of premium known as advance premium deposit was deposited with OP no.1 for ensuring instant availability of health cover to its employees and their family members.
- It is also stated that as per the terms and conditions of the policy relating to addition and deletion of employees and their family members to be covered, in the month of December 2009 complainant no.1 sent an endorsement list bearing no. 49 and the same was duly received being HWT 0000 1682-049-01 and was also assigned by both the OPs.
- A premium of Rs.4,09,166/- was collected by the OPs from complainant no.1 in advance without even actually affecting the changes. It was also specifically mentioned that all other terms conditions, provisions and warranties of the policy remain unaltered.
- It is stated that the name of complainant no. 2 namely Ms. Ruchi Mahajan was included and as per the terms of the insurance policy she was ‘primary’ insured and her parents namely late Sh. P D Mahajan and Smt. Shubh Mahajan were in the dependent beneficiary category. The cover for complainant no.2 was for amount of Rs. 2,50,000/-. The OPs duly acknowledged the said fact and issued TPA cards to the insured.
- It is further stated that in the month of February 2010 father of the complainant no.2 i.e Mr PD Mahajan who was endorsed and registered dependent beneficiary, fell ill and he was on 18.02.20 admitted to Fortis hospital which is one of the network hospital that is pre-approved and who's rates are also pre agreed for different medical treatments by the OP.
- It is further stated that a cashless approval form was sent to the OP and in the said form, the complainant had mentioned the age of the father of the complainant no.2 as 70 years but the approval was declined by office without assigning any reason. After the complaint made several visits to the office of the OP, they got to know that the approval for providing cashless treatment to the insured had been rejected on account of discrepancy in the age of late Sh. PD Mahajan. It was stated that the age mentioned in the list differs from the dependent’s actual age and therefore the dependent could not get the benefit of the policy.
- It is stated by the complainant that as per the terms and conditions of the policy, a dependent parents should not be more than 80 years of age and should be natural or legally adopted mother or father of the primary insured. It is further stated by the complainant that the age of the dependent is filled in manually in the list and the difference in the age appearing in the list could be best described as a typographical error.
- It is further stated that the office of the OP assured the complainant that soon after the age correction endorsement is made by the OP, the payment under the claim will be made. It is stated that after the death of Sh. PD Mahajan on 03.03.2010, a claim form was duly submitted along with all supporting documents detailing the information as required about late Shri PD Mahajan on 26.03.2010 and on 30.03.2010 a letter was received from OP no. 2 wherein some documents were asked for. Another letter was issued by the OP dated 17.04.2010 asking for new and separate set of documents. All such documents were duly provided by complaint no. 2. However, vide email dated 20.07.2010 the OPs stated that the claim could not be processed since the policy is over and the APD has been refunded to complainants.
- It is stated by the complainant that the said action of the OP clearly enumerates that the intention of the OP from the very beginning was to frustrate the valid claim of the complainant on one ground or the other. It is further stated that at the time of submission of the claim, the policy was valid and in existence and therefore the reason given by the OP that the policy is over is clearly unjustified.
- It is stated that vide email dated 18.08.2010 OP no.2 rejected the claim of the complainant no. 2 where in it was stated that the claim is closed due to the non -receipt of endorsement for the correct age.
- It is further stated by the complainant that the rejection on the ground of age discrepancy is flimsy and smacks of malafide on the part of OP. It is stated that age discrepancy could not deprive the complainant of their lawful claim because in terms of the policy, the dependent should not be above 80 years of age and thus the terms of the policy were not violated. It is also stated that the OP were not prejudiced in any manner due to the said typographical error.
- It is stated by the complainant that the OPs have failed to attend to the specific complaint of the complainant and have also failed and neglected to provide a satisfactory solution to their complaint which amounts to deficiency in service.
- It is further stated by the complainant that this Commission has jurisdiction to try the present complaint as the service level agreement dated 06.07.2009 between the complainant and the OP was entered into at New Delhi which is within the jurisdiction of this Commission.
- It is stated by the complainant that the date of birth of the dependent of the insured was given as 16.08.1955 whereas in fact his date of birth was 09.02.1940 which can at best be described as a typographical error. It is also submitted that proof of age i.e PAN card and the driving licence were already submitted to the OP along with the endorsement list in which the name of the insured person was included therefore there is no question of concealment of age by the complainant.
- It is further stated by the complainant that OP no. 2 was appointed as administrated by OP no.1 for smooth administration and working as an intermediary between the insurance provider and insured and as per the service level agreement dated 06.07.2009 wherein it is clearly provided that for providing cashless claims the TPA i.e OP no. 2 should process the claims without waiting for any approval from the insurer.
- On the other hand, the OP I in its reply has stated that the complaint has not been filed in competent jurisdiction. It is stated that the insurance policy was obtained by the complainant from Jaipur office and the patient was admitted and treated at Mohali therefore no cause of action has arisen within the jurisdiction of this Commission.
- It is stated at the time of insurance, the complainant had misrepresented the age of the insured person and in case of health insurance, the age of the insured is relevant and very material for the assessment of risk. Since there was a misrepresentation of age, no claim is admissible.
- It is further stated that claim in respect of treatment of illness is admissible in terms of the policy, scope and terms and conditions and then to the extent not exceeding the amount of insurance liability. The age of an insured person for the purpose of health insurance is a factor very relevant and material for the risk assessment and cannot be brushed aside by stating it to be a mere typographical error or as a technical objection. It is a misleading information intended to deprive the insurer from property assessing the risk.
- It is stated by the OP that original documents were requested as a normal practice and for verification in view of the discrepancy noticed. Several letters and email were written to the insured but it did not evoke any cooperation from the complainant. Copies of these letters and email are placed on record. The decision to deny liability was taken by OP on the basis of documents and information on record and hence there is no deficiency in service or any unfair trade practice.
- OP2 has stated that the complainant is not a consumer as it has not hired or availed of any services of the answering respondent for a consideration. There is no privity of contract between the OP and the complainant.
- It is stated that OP no 2 has not undertaken any service to be performed to complainant in pursuance of a contract with him and therefore there can be no allegation of deficiency of service.
- It is further stated that at the time of insurance, the complainant had mis-represented the age of the insured person. Wrong mentioning of the age of the persons insured is a very relevant factor for health insurance. No claim is therefore admissible. It is stated that the decision was taken by OPs on the basis of documents and information on record and hence there is no deficiency in service or any unfair trade practice on part of the OPs.
This Commission has carefully gone through the reply, rejoinder, evidence affidavits and written submissions of all the parties. The objection raised by the OP that this Commission does not have the territorial jurisdiction to entertain the complaint is not based on cogent reasoning as all the correspondence of the complainant with OP-2 has taken place at Okhla and therefore this Commission has jurisdiction to entertain the complaint.
Having gone through all the documents specially the policy filed by the OP, it is observed that as per the terms and conditions for the grant of group insurance policy is that, ‘a dependent parents should not be more than 70 years of age and should be natural or legally adopted mother or father of the primary insured’. This condition is satisfied in the case of the complainant.
It is also observed from the policy provided by the OP that it is the age of the primary insured which is the determining factor and not the age of parents. We are conscious that it is a group insurance policy unlike individual policy where the premium is decided on the basis of the age of each member of the policy.
The reasoning given by the complainant no.2 regarding wrong mentioning of the age of her father seems plausible as there are several people involved in feeding the data and the policy itself is a group insurance i.e involving many. In case, the complainant desired to cheat the OPs, she would not have provided the requisite documents of her father with correct DOB. It is also not in doubt that at the time of submission of the claim, the policy was valid and in existence. It is seen that the words mentioned in the reply of the OP that a dependent parents should not be more than 70 years of age and should be natural or legally adopted mother or father of the primary insured, the words state should not be more than 70 years. Admittedly, the father of the complainant was at the time of his death aged 70 years and not more than 70 years.
Keeping the above observations in mind, this Commission is of the view that OP No.1 has been deficient in providing services to the complainant no 2 in closing her claim after waiting till the term of the policy was over. This Commission therefore directs the OP no.1 to pay to the complainant no. 2, the sum of Rs. 2,50,000/- i.e sum assured. The OP No. 1 is also directed to pay a sum of Rs. 50,000/- on account of harassment caused to the complainant. These amounts shall be payable by the OP within three months from the date of this order failing which they would be liable to pay interest @6% p.a from the date of claim till its realisation.
File be consigned to the record room after giving copy of the order to the parties as per rules.
Order be uploaded on the website.
(Dr. RAJENDER DHAR) (RASHMI BANSAL) (MONIKA SRIVASTAVA)
MEMBER MEMBER PRESIDENT
