BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL COMMISSION, JALANDHAR.
Complaint No.318 of 2019
Date of Instt. 13.08.2019
Date of Decision:06.06.2022
Seema Randhawa W/o Paramjit Singh Randhawa, aged 48 years, resident of VPO Daduwal, Tehsil Phillaur, District Jalandhar.
..........Complainant
Versus
Future Generali India Insurance Co. Ltd., 3rd Floor, SCO 5 & 6, Puda Complex, Court Road, Jalandhar, through its Branch Manager, Jalandhar.
….….. Opposite Party
Complaint Under the Consumer Protection Act.
Before: Dr. Harveen Bhardwaj (President)
Sh. Jaswant Singh Dhillon (Member)
Present: Sh. Amrit Pal Singh, Adv. Counsel for the Complainant.
Sh. R. K. Sharma, Adv. Counsel for the OP.
Order
Dr. Harveen Bhardwaj (President)
1. The instant complaint has been filed by the complainant, wherein it is alleged that the complainant has purchased/renewed health insurance policy from the OP vide policy no.HO256500 for the period i.e. 10.05.2018 to 09.05.2019. The complainant has originally purchased said insurance policy from the OP in the year 2017, since then it has continually renewed on payment/acceptance of insurance premium. The OP has provided medical cover for all ailments or diseases etc vide it’s above mentioned health/mediclaim insurance policy, duly issued upon receipt/acceptance of premium for said health insurance policy. In the month of March 2019, the complainant had to be admitted in hospital due to her emergent critical medical condition i.e. multiple fibroid in uterus. As such concerned doctor advised her to immediately undergo surgery for such critical health condition. So, the complainant got admitted for medical treatment to undergo surgery for such ailment from the Smt. Parwati Devi Hospital, Amritsar, during the period 13.03.2019 to 15.03.2019. The total medical expenses occurred for her treatment was nearly Rs.83000/-. The complainant was provided proper medical treatment after emergent surgery by the doctor of said hospital, so the complainant’s condition became stable within few days. Accordingly, she was discharged upon her stable condition by concerned doctor. Thereafter, complainant given medical prescription or dosage to be taken regularly for some time. Ultimately she recovered her good health. The complainant during the period of treatment in said hospital intimated her insurance claim to the OP with all necessary formalities by proper procedure. She has filed the entire necessary documents/bill/diagnose summary etc. for reimbursement of her medical treatment or expenses alongwith claim form with the OP. But the OP arbitrarily denied reimbursing her genuine insurance claim. The OP astonishingly not only failed to provide cashless facilities for her insurance claim settlement, but also till date not paid reimbursed the insurance claim amount to the complainant. Even though all the formalities have duly been done by her. The OP vide its letter dated 03.042019 malafidely and arbitrarily repudiated insurance claim lodged with it, on the pretext that the claim does not fall under purview of policy, thus it falls under exclusion clause 1. Exclusion applicable for benefits other than benefits 13, (b) the policy will exclude any medical expenses incurred during the first consecutive 24 months during which the insured person has been covered under a health insurance policy with us, in connection with internal congenital anomalies, cataracts, benign prostatic hypertrophy, hernia of all types, deviated nasal septum, hypertrophied turbinate, hydrocele, all type of sinuses, fistulae, haemorrhoids, fissure inance, dysfunctional uterine bleeding, fibromyoma endometriosis, hysterectomy, all internal or external tumours/cysts/nodules/polyps of any kind including breast lumps with exception of malignant tumour or growth, surgery for prolapsed inter vertebral disc unless arising from accident, surgery of varicose veins and varicose ulcers, any types of gastric or duodenal ulcers, stones in the urinary and bellary systems, surgery on ears and tonsils. But here it is worth to mention that the OP has never serve any such exclusion clauses to the complainant nor informed any such terms or conditions alongwith the insurance policy to complainant till date. Further, there are no such conditions or exclusion clauses specifically or legibly been mentioned in the insurance policy. Hence the arbitrary repudiation of genuine claim by the OP is illegal. It is clear from the general terms of contract as well as rules and regulation laid down by the IRDA that the individual’s right to avail health insurance is an inalienable part of the right to health care. Health insurance with the exclusion clauses hits at the basic right of an individual to avail of insurance for prevention, diagnosis, management and cure of diseases. Excluding any particular category of individuals from obtaining health insurance or having their claims honoured, based on such vague conditions would be per-se discriminatory and violative of the individual’s right to health. The repudiation of insurance claims on the pretext that its falls within exclusion clause is illegal, arbitrarily and unjustified. Because she has not been treated immediately after taking the insurance policy from the OP. Rather the complainant was regularly provided insurance cover for continued period of two years. There was not even a single day break in the insurance policy. Nor previously there was any single insurance claim was lodged. Hence the OP violated their own rules and regulations. The OP till date has not paid the insurance claim to the complainant even though the numerous requests have been made in this regard. Rather the OP has malafidely issued repudiation letter dated 03.04.2019 and denied the payment of insurance claim. The act and conduct of the OPs has caused a great mental agony, tension and harassment to the complainant and as such, the present complaint filed with the prayer that the complaint of the complainant may kindly be accepted and OPs be directed to pay insurance claims for medical treatments lodged for an amount of Rs.83,000/- alongwith interest @12% till realization. Further, OPs be directed to pay a compensation of Rs.2,00,000/- for causing mental tension and harassment to the complainant and OPs be also directed to file litigation expenses.
2. Notice of the complaint was given to the OP, who filed written reply and contested the complaint by taking preliminary objections that the complaint is not maintainable against the OP, as such the same is liable to be dismissed. The complainant was in the second year of the health insurance policy with the OP when the claim arose. Admittedly, the complainant was known case of multiple fibroid uterus and was diagnosed as multiple Fibroid Uteru by Smt. Paarwati Devi Hospital, Amritsar and underwent surgery/procedure TLH with BSC. As per exclusion clause 1(b) of the policy terms and conditions is not payable during first two year of the policy and hence the claim of the complainant was repudiated vide letter dated 03.04.2019. It is further averred that there is no deficiency in service or negligence or unfair trade practice on the part of the OP. The claim of the complainant has been rightly repudiated as per terms and conditions of the insurance policy vide letter dated 03.04.2019. Repudiating the claim as per terms and conditions of the insurance policy does not amount to any deficiency in service or negligence or unfair trade practice, as such the complaint against the OP is liable to be dismissed. On merits, the factum with regard to purchasing health insurance policy by the complainant is admitted and repudiating the claim of the complainant is also admitted, but the other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.
3. Rejoinder to the written statement filed by the complainant, whereby reasserted the entire facts as narrated in the complaint and denied the allegations raised in the written statement.
4. In order to prove their respective versions, both the parties produced on the file their respective evidence.
5. We have heard the learned counsel for the respective parties and have also gone through the case file very minutely.
6. The complainant has purchased health insurance policy from the OP in the year 2017 and since then it was continually renewed and was valid upto 09.05.2019 as per Ex.C-1 and Ex.C-2. It has been alleged by the complainant that in the month of March 2019, the complainant had to be admitted in the hospital due to her emergent critical medical condition i.e. multiple fibroid in uterus and she had to undergo surgery due to her critical health condition. She remained admitted in Parwati Devi Hospital Amritsar from 13.03.2019 to 15.03.2019 and spent about Rs.83,000/- on her treatment. The insurance company was intimated. The insurance claim was filed, but the OP repudiated the claim on the ground of exclusion clause as per terms and conditions of the policy and the complainant was in the second year of policy with the OPs and as per the exclusion clause of policy terms and conditions, the same is not payable during first two years of the policy and the claim was repudiated. The complainant has proved on record the policy Ex.C-1 & Ex.C-2, repudiation letter Ex.C-3, discharge summary Ex.C-4, prescriptions of the doctor, reports of the hospital, diagnosis detail, bills and receipts Ex.C-5 to Ex.C-23. The contention of the complainant is that the complainant was never made aware of the exclusion clause as the policy documents were never given to the complainant nor the same was ever read over to the complainant that as per exclusion clause of the terms and policy, the reimbursement is not to be made during first two years of the policy.
7. On the other hand, the OPs have filed the insurance policy and proposal form Ex.O-1 and Ex.O-2. As per the terms and conditions of the policy, there is exclusion clause, which reads as under:
“Exlusion-1.Exclusions applicable for all Benefits other than Benefit 13
b) the Policy will exclude any Medical Expenses Incurred during the first consecutive 24 month during which the Inured Person has been covered under a health Insurance Policy with Us, in connection with Internal Congenital Anomalle, cataracts, Benign Prostatic Hypertrophy, hernia of all types, Deviated Nasal Septum, Hypertrophied Turbinate, Hydrocele, all types of sinuses, Fistulae, hemorrhoids, fissure in ano, dysfunctional uterine bleeding, Fibromyoma Endometriosis, Hysterectomy, all internal or external tumors/cysts/nodules/polyps of any kind including breast lumps with exception of malignant tumor or growth, surgery for prolapsed Inter vertebral disc unless arising from accident, surgery of varicose veins and varicose ulcers, any types of gastric or duodenal ulcers, stones in the urinary and biliary systems, surgery on ears and tonsils”.
8. As per the record and submission of the complainant, the complainant has purchased the policy in the year 2017 and two years have not passed as yet at the time of surgery. Perusal of the insurance policy shows that the sum insured was Rs.5,00,000/- and the risk was covered, to the tune of Rs.5,00,000/- for the period from 10.05.2018 to 10.05.2019. The insurance was purchased for the first time in the year 2017. The complainant was admitted in the hospital on 13.03.2019 and was discharged on 15.03.2019 as per discharge summary and the period of 22 months was already covered when the complainant was admitted in the hospital. The risk covered was Rs.5,00,000/-, the amount spent on the treatment was Rs.83,000/- only, which was less than the amount of Rs.5,00,000/- i.e. the sum insured.
9. The contention of the OP that the time was not completed, therefore the complainant is not entitled to reimbursement, is not tenable as only two months were left to complete 24 months as per the allegations of the OP, even otherwise the policy was for year to year basis and it will expire after the completion of 12 months and in such circumstances, the period of 24 months will never be covered. Moreso, if the insured becomes seriously ill, he or she cannot wait for 24 months to complete if emergent surgery or emergent treatment is required for the disease. A person gets insurance only for their own benefit and comfort and not to cause mental tension to self, thinking that the period of insurance has not yet completed. Had the complainant be aware of the exclusion clause of completing 24 months, she could have waited for two months, if her health condition had allowed, she could have not gone for surgery immediately before completion of 24 months.
10. The contention of the complainant is that the OP has never supplied any such exclusion clauses nor informed any such terms and conditions alongwith the insurance policy. No document has been filed by the OPs to rebut the allegation by any cogent and convincing evidence that when and in what manner the said terms and conditions and exclusion clause were ever supplied to the complainant or the same were ever explained or read over to the complainant. It has also not been proved by the OPs that any email was ever sent to the complainant regarding the terms and conditions and exclusions clause specially. This shows that these terms and conditions specially exclusion clauses were never brought to the notice of the complainant. It has been held by the Hon’ble National Commission, in case FA No.2011 of 2019, titled as “National Insurance Co. Ltd. Vs. M/s Saraya Industries Ltd.”, that where there is no evidence on the record showing that the copies of terms and conditions of insurance policy had been supplied to the complainant, no presumption can be raised regarding the supply of terms and conditions under the law.
11. From the documents, it is proved that the terms and conditions as well as exclusion clause were never supplied to the complainant and as such, the complainant is entitled for the relief as claimed.
12. In the light of above detailed discussion, the complaint of the complainant is partly accepted and OP is directed to reimburse mediclaim amount of Rs.83,000/- alongwith interest @ 9% per annum from the date of lodging the claim, till its realization and further OPs are directed to pay Rs.10,000/- as compensation for causing mental tension and harassment to the complainant and Rs.5000/- as litigation expenses. The compliance of the order be made within 45 days from receipt of copy of this order. This complaint could not be decided within stipulated time frame due to rush of work.
13. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.
Dated Jaswant Singh Dhillon Dr. Harveen Bhardwaj
06.06.2022 Member President
