DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, NORTH-WEST,
GOVT. OF NCT OF DELHI
CSC-BLOCK-C, POCKET-C, SHALIMAR BAGH, DELHI-110088.
CC No: 490/2018
D.No._________________________ Dated: _________________
IN THE MATTER OF:
VIJAY KUMAR BANGA,
S/o SH. BANARASI DASS BANGA,
R/o D-13-A/29,MODEL TOWN-II,
DELHI-110009.… COMPLAINANT
Versus
1. IFFCO-TOKIO GENERAL INS. CO. LTD.,
(THROUGH ITS BRANCH MANAGER),
UNIT 23-24, 1st FLOOR, PEARL OMAXE MALL,
NETAJI SUBHASH PLACE,
PITAM PURA, DELHI-110034.
2. IFFCO-TOKIO GENERAL INS. CO. LTD.,
(THROUGH ITS BRANCH MANAGER),
IFFCO SADAN, C1 DISTRICT CENTRE,
SAKET, NEW DELHI-110017. … OPPOSITE PARTY (IES)
CORAM:SH. M.K. GUPTA, PRESIDENT
SH. BARIQ AHMED, MEMBER
MS. USHA KHANNA, MEMBER
Date of Institution: 20.07.2018
Date of decision: 06.11.2019
SH. M.K. GUPTA, PRESIDENT
ORDER
1. The complainant has filed the present complaint against OPunder Section 12 of the Consumer Protection Act, 1986 therebyallegingthat the complainant is having Medi-Claim policy since 28.11.2008 till 27.11.2018 with The Oriental Ins. Co. Ltd. and in the month of
CC No.490/2018 Page 1 of 8
November-2013, one agent of OP visited the premises of the complainant and asked to take the Medi-Claim policy and shown benefits in the company’s Medi-Claim policy. Thereafter, as per assurance of the agent of OP, the complainant took the OP’s Medi-Claim policy in November-2013 to November-2014 and till date the policy is alive and the latest policy insured period was 29.11.2017 to 28.11.2018 and the sum insured amount of Rs.10,00,000/- for the said policy and the complainant was regularly paying its premium and the insured person’s against the policy are Vijay Kumar Banga (self) and his wife namely Smt. Neeta Banga. In the month of November-2016, the complainant was having severe pain in chest and the complainant was admitted in Max Super Speciality Hospital, Saket, New Delhi on 02.11.2016 and was discharged on 04.11.2016 and the hospital raised a bill of Rs.3,93,144/- which was paid by the complainant to hospital. The complainant further alleged that OPs are not releasing the claim on one pretext and other and the complainant supplied copies ofall relevant documents to OP but the officials of OP is not giving proper response in the matter nor releasing the claim. Thereafter, the complainant approached to OP uncounted times but there is no proper response in the matter by them nor they are releasing the claim and the treating doctor has also given a certificate and OP failed to release the claim despite repeated requests of the complainant which has caused great mental tension pain, agony,
CC No.490/2018 Page 2 of 8
harassment, inconvenience and loss to the complainant which shows deficiency in service on the part of OP.
2. On these allegations the complainant has filed the present complaint praying for direction to OP to pay a sum of Rs.3,93,144/- alongwith interest @ 24% p.a. till its realization to the complainant as well as compensation of Rs.2,00,000/- for causingdamages, mental agony and harassment and has also sought Rs.5,500/- towards the legal notice charges and has also sought cost of litigation of Rs.25,000/-.
3. OP hasbeen contesting the complaint and has filed written statement andOP submitted that the complaint is absolutely false, frivolous, misconceived and is not maintainable andis liable to be dismissed and there is no deficiencyin service on the part of OP. OP further submitted that the complainant was admitted in Max Super Speciality Hospital for treatment of Ischemic Cardiomyopathy from 02.11.2016 till 04.11.2016 with respect to which he incurred an expense of Rs.3,93,144/- and a cashless request was received for the said claim which could not be processed based on the documents submitted during the cashless request on the basis of the terms & conditions of the policy and it was observed that the insured had not revealed/disclosed the past medical history of hypertension & diabetes mellitus in the proposal form while taking policy from OP and the said cashless request was denied vide letter dated 02.11.2016 and the complainant submitted documents for
CC No.490/2018 Page 3 of 8
re-imbursement of the said claim and on the scrutiny of the documents submitted and it was observed that there were a few essential documents/information that was required for the purposes of processing the claim. OP further submitted that a discrepancy letter dated 07.07.2017 was issued to the complainant wherein the complainant was requested to send certain essential documents within 15 days from the receipt of the letter but a reply was not received from the complainant and two reminders were sent to the complainant for the submission of the said essential documents vide letters dated 26.08.2017 & 11.09.2017, the same were still not submitted by the complainant and due to non-co-operation and in the absence of response of the letters, the claim was repudiated vide letter dated 14.10.2017. OP further submitted that the complainant has purchased an Individual Medi-shield policy vide policy no. 52310656 from OP for the duration of 29.11.2016 to 28.11.2017 also covering his wife namely Neeta Banga for an amount of Rs.5,00,000/- each alongwith a Critical Illness coverage of Rs.5,00,000/- alongwith cumulative bonus of Rs.75,000/- subject to certain conditions and exclusions which has been clearly, specifically and categorically has been mentioned in the said policy documents.
4. The complainant filed rejoinder and denied the submissions of OP and further submitted that OP has taken a misleading plea.
5. In order to prove his case, the complainant filed his affidavit in
CC No.490/2018 Page 4 of 8
evidence and also filed written arguments. The complainant also placed on record copies of provisional cover notes issued by The Oriental Ins. Co. Ltd., copy of Individual Mediclaim Policy schedule no.271601/48/2013/3737 period from 28.11.2012 to 27.11.2013 (mid-night) issued by The Oriental Ins. Co. Ltd., copies of Individual Medi-shield Policy the Schedule no.52310656 period from 28.11.2013 to 27.11.2014 (mid-night), no. 52421316 period from 28.11.2014 to 27.11.2015 (mid-night), no. 52552660 period from 28.11.2015 to 27.11.2016 (mid-night), no.52710831 period from 29.11.2016 to 28.11.2017 (mid-night) and no.52872395 period from 29.11.2017 to 28.11.2018 (mid-night) issued by OPs, copy of discharge summary issued by Max Health Care, copy of Duplicate Inpatient Bill (detailed) dated 04.11.2016, copy of Claim Form-8, copy of cheque, copy of PAN card of the complainant, copy of passport, copy of aadhar card, copies of letters dated 15.11.2016, 27.02.2017, 16.03.2017, 12.04.2017, 16.05.2017, 07.07.2017, 12.07.2017, 02.09.2017 & 13.09.2017 sent by the complainant to OP regarding request for payment of Medi-Claim covered under Insurance Policy no. 52552660 through speed post, copies of repudiation letters dated 23.05.2017 & 14.10.2017 sent by OP to the complainant, copy of discrepancy letter (without any prejudice) dated 11.09.2017 sent by OP to the complainant and copy of Certificate dated 15.09.2017 issued by Max Healthcare Hospital to the effect that the complainant was admitted in the hospital on
CC No.490/2018 Page 5 of 8
02.11.2016 and was discharged on 04.11.2016 and the complainant underwent “Coronary Angiography” and “Double Chamber Pacemaker”.
6. On the other hand, Sh. Pankaj Dhingra, Legal Head of OP filed his affidavit. OP also filed copies of policies nos.52310656 period from 28.11.2013 to 27.11.2014, no.52421316 period from 28.11.2014 to 27.11.2015, no. 52552660 period from 28.11.2015 to 27.11.2016, no. 52710831 period from 29.11.2016 to 28.11.2017 and no. 52872395 period from 29.11.2017 to 28.11.2018 issued by OP, copy of terms & conditions of the policy issued by OP, copy of Cashless Denial letter dated 02.11.2016, copy of plan of action sheet, copy of Abnormal ECG, copy of discharge summary, copies of discrepancy letters dated 07.07.2017, 26.08.2017 & 11.09.2017, copy of repudiation letter dated 14.10.2017 and copy of letter dated 15.09.2017 issued by Max Healthcare. OP also filed written arguments.
7. This forum has considered the case of the complainant as well as OP in the light of evidence and documents placed on record by the parties. The documents and evidence of the parties shows that the complainant was admitted in Max Super Speciality Hospital, Saket, New Delhi on 02.11.2016 due to pain in the chest and Coronary Artery Disease, Single Vessel Disease (02.11.2016) complete heart block with wide QRS severe Bradycardia-Dual Chamber PPI (02.11.2016) Hypertention Type 2 Diabetes Mellitus was conducted
CC No.490/2018 Page 6 of 8
on the same date i.e. 02.11.2016 and diagnosed with single vessel diseaseand was discharged from the hospital on 04.11.2016. We are of opinion that OP has failed to prove its defence that the complainant was suffering from pre-existing disease. The discharge summary/progress sheet issued by the hospital shows that there was no history of any heart disease of the complainant and OP is not justified in contending that the complainant has concealed about his diabetes at the time of taking the policy. A person taking a Mediclaim policy from an insurance company is not expected that he will suffer from such a disease/ailment after taking Mediclaim policy. The heart disease can occur to any person at any time and the person is not expected to know this fact in advance as to when he will be suffering from such a disease. So, the defence taken by OP that the complainant was suffering from heart disease and has concealed the fact and is not available to OP and we are of opinion that OP has wrongfully repudiated the claim of the complainant. Thus, OPis held guilty of deficiency in service.
8. Thus, holding guilty for the same, we direct OP as under:
-
ii) To pay to the complainant an amount of Rs.50,000/- as compensation for harassment and mental agony suffered.
-
CC No.490/2018Page 7 of 8
9. The above amount shall be paid by OPto the complainant within 30 days from the date of receiving copy of this order failing which OP shall be liable to pay interest on the entire awarded amount @ 10% per annum from the date of receiving copy of this order till the dateof payment. If OPfails to comply with the order within 30 days from the date of receiving copy of this order, the complainant may approach this Forum u/s 25 of the Consumer Protection Act, 1986.
10. Let a copy of this order be sent to each party free of cost as per regulation 21 of the Consumer Protection Regulations, 2005. Thereafter file be consigned to record room.
Announced on this 6thday of November, 2019.
BARIQ AHMED USHA KHANNA M.K. GUPTA
(MEMBER) (MEMBER) (PRESIDENT)
CC No.490/2018 Page 8 of 8
