DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II
Udyog Sadan, C-22 & 23, Qutub Institutional Area
(Behind Qutub Hotel), New Delhi-110016
Case No.539/2011
- M/s GFB Great Foods Pvt. Ltd.
(Formally known as M/s GFB Great Company)
India Food & Beverages Company Pvt. Ltd.
Having its registered office at :
2/11B, Basement, Jangpura A,
New Delhi.
And its Manufacturing Unit at:
Plot No. 36, Sector-3,
IMT Manesar, Haryana-122050
- Mr. Alejandro Nieto,
Director (Finance),
M/s GFB Great Foods Pvt. Ltd.
Plot No. 36, Sector-3,
IMT Manesar, Haryana-122050
….Complainants
Versus
- Iffco-Tockio General Insurance Company Ltd.
Iffco Sadan, C1 District Centre,
Saket, New Delhii-110017.
- Paramount Health Services (TPA) Pvt. Ltd.
D-39, Okhla Industrial Area,
Phase-1, Near D.D. Motors,
New Delhi-110020
….Opposite Parties
Date of Institution : 28.12.2011 Date of Order : 14.11.2018
Coram:
Sh. R.S. Bagri, President
Ms. Naina Bakshi, Member
Ms. Kiran Kaushal, Member
ORDER
Member - Kiran Kaushal
Brief facts as stated by the complainant are :
- Complainant No. 1, M/s GFB Great Foods Private Limited had taken a policy for its employees and their families under the Group Medical Policy being Policy No. 52191924 dated 24.05.2011. The said policy was issued by OP-1 i.e. Iffco Tokio General Insurance Company Limited.
- The group medical policy coverage included mediclaim for Mr. Alejandro Nieto (Complainant No.2) along with his family who is an employee of complainant No. 1. It is stated by complainant No. 1 that Mrs. Xiaena wife of complainant No. 2 was taken ill and was admitted in the Medanta Hospital, Gurgaon on 03.07.2011 with severe pain in abdomen. An ultrasound test of Mrs. Ximena Alvarez was conducted which showed an ovarian bilobed cyst. She was treated and discharged from hospital on 05.07.2011. The total amount paid for the treatment of hospitalization of Mrs. Ximena Alvarez was Rs.51,107/- which was paid by complainant No.2, who through the company made a medical insurance claim of Rs.51,107/- by submitting his claim form long with other requisite documents on 11.07.2011.
- Complainant No. 2 was informed by an email dated 26.08.2011 of the repudiation of his claim on the ground of “pre-existing disease”. The reasons stated for repudiation was that Mrs. Ximena Alveraz has a history of Mirena Insertion and current ailment is complication of the same. Complainant No. 2 vide email dated 29.08.2011 requested OP-1 to provide justification and medical opinion in support of repudiation and denial of claim. However despite his best efforts, OP-1 did not provide any document or opinion of any registered medical practitioner. Complainant no. 2 then sent a legal notice to OP-1, however, no reply has been received on its behalf. Complainant No. 2 served notice to OP-2 also i.e. Paramount Health Service (TPA) Private Limited. OP-2 replied to the notice stating that Mrs. Ximena Alveraz has a history of Mirena Insertion and the current ailment is a complication of the same and therefore claim of the complainant has been repudiated.
- Complainant No.2 alleges that despite the claim having being made, OPs have not paid money of legitimate claim filed by the complainant. Aggrieved by the circumstances stated above, Complainant No. 2 approached the Forum with the prayer to pay Rs.51,107/- to the complainants, pay interest @ 15% per annum on the principal amount and pay pendentelite interest and future interest @ 15% per annum till realization of the said claim. It is further prayed that Rs.2,00,000/ be paid to the complainant towards mental agony, harassment and damages suffered by the complainants.
2. OP resisted the complaint inter-alia stating that on scrutiny of the medical documents of the wife of complainant No. 2, it was found that she was brought to the hospital on 03.07.2011 complaining of acute abdominal pain. The examination of CECT (whole abdomen) suggested the following:-
- High density free fluid in abdomen & pelvis? Haemorrhagic/Infected
- Bilobed cyst in right ovary;
- Follicular/ luteal cyst in left ovary
OP states that it was further found that complainant No.2’s wife was diagnosed with ‘Pelvic Infection’ which was the cause of her abdominal pain. It transpired that the patient had a history of ‘Mirena Insertion’ which is an intrauterine device which is used to prevent conception. OP-1 further states that the patient had undergone this procedure about 1 & 1½ year (i.e. prior to, policy inception). It may be stated ‘Pelvic Infection’ is a known complication of ‘Mirena Insertion’ and this condition is often referred to as ‘Pelvic inflammatory disease’ (PID). It is a known fact that PID is a cause of pain and various side effects and in some cases may require surgery. It was next observed that from the medical record of wife of complainant No. 2 that she was given conservative treatment in the hospital comprising administration of injectable antibiotics, given for treating infections and painkillers. OP-2 submits that it was in these circumstances and the purported medical condition that the wife of complainant No.2 was suffering from on ailment which was related to “pre-existing condition”.
2.1 OP-1 further states that it is a matter of record that any pre-existing condition and its complications are specifically excluded from the coverage under the policy. OP-1 reiterates that complainant No. 2 was well aware about the condition of ‘Mirena Insertion’ of his wife, however, no disclosure of this condition was made notwithstanding that it was a material fact for the purposes of obtaining a medical policy. OP-2 reiterates that the repudiation of the claim of the present case was absolutely justified and in consonance with the terms of the applicable policy based on a medical expert opinion obtained by OP-1.
3. Rejoinder and evidence by way of affidavit has been filed by the complainant No. 2 wherein all the averments in the complaint have been reiterated in the rejoinder as well as in evidence. Complainant has annexed following documents in support of his case – copies of Insurance Policy, Medial Certificate, Hospital Bill, Mails and Legal Notice.
4. Evidence by way of affidavit of Shri Sirkant Charan, Vice President with M/s IFFCO Tokio General Insurance Co. Ltd. has been filed on behalf of OP-1.
5. Written arguments have been filed by the parties.
6. We have heard arguments on behalf of the complainant. No one appeared on behalf of the OP-1 to advance oral arguments despite opportunity being granted to them.
7. Admittedly, Complainant No. 1 had taken a group medical policy for its employees which included complainant no. 2 along with his family, from OP No.1. Wife of complainant No. 2 was taken ill in the insured period and was admitted in Medanta Hospital with severe pain in the abdomen. As per records annexed as Annexure-A2, patient was investigated and ultrasound showed a right ovarian bilobed cyst. Further investigations were required to decipher the nature of the cyst and also the pain was not subsiding with routine medications. Therefore, wife of complainant No.2 was admitted to the hospital. Total amount of Rs.51,107/- was paid for the treatment which was paid by complainant No. 2. Complainant No. 2 through complainant No.1 made a medical insurance claim which was repudiated by OP No. 1 mainly on the ground of ‘pre-existing’ disease alleging that the wife of complainant no. 2 had a history of Mirena Insertion and the current ailment is a complication of the same.
8. It is pertinent to note that the Mirena is an intrauterine device (IUD) which is a small, flexible contraceptive device that is inserted into the uterus and is the most popular form of reversible birth control in the world. It prevents sperm from joining with an egg by interfering with the movement of the sperm towards the egg and also changes the lining of the uterus.
Forum is of the opinion that use of contraceptive device cannot be termed as a disease or any ailment which required disclosure to the Insurance Company. Therefore, the ground taken by OP-1 to repudiate the claim of complainant no. 2 is frivolous and non-justifiable.
- Additionally, it is noticed that OP-1 has not produced any documentary evidence or expert medical opinion in support of its case. Onus to prove that the complainant No. 2’s wife was suffering from pre-existing disease as per settled law was on OPs. But, OPs have failed to prove that there was pre-existing disease and the assumption itself is based on conjectures and surmises.
- Therefore, this Forum is of the opinion that OP-1 has indulged in unfair trade practice and deficient in service as it has failed to reimburse the claim of the complainants under a valid policy. Hence, compliant is allowed and OP-1 is directed to pay an amount of Rs.51,107/- alongwith interest @ 9% per annum from the date of filing the claim till realization within a period of two month from the date of this order.
Failing which OP-1 shall become liable to pay Rs.51,107/- @ 12% per annum from the date of filing of the claim till realization. Additionally OP-1 is directed to pay Rs.20,000/- towards mental agony, harassment and damages suffered by the complainant.
Let a copy of this order be sent to the parties as per regulation 21 of the Consumer Protection Regulations. Thereafter file be consigned to record room.
Announced on 14.11.18
