Punjab

Sangrur

CC/362/2017

Sushil Kumar - Complainant(s)

Versus

IFFCO TOKIO General Insurance Company Limited - Opp.Party(s)

Sh.J.S.Sahni

15 Dec 2017

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.

                                               

                                                Complaint No.    362

                                                Instituted on:      25.07.2017

                                                Decided on:       15.12.2017

 

Sushil Kumar son of Tarsem Lal, resident of H.No.170, Ward No.3, Street No.1, Opposite BDO Office, Ajit Nagar, Sunam, Tehsil Sunam, District Sangrur.

                                                        …Complainant

                                Versus

1.             IFFCO TOKIO General Insurance Company Limited, Branch Office: 2^nd Floor, Above Hot Chop Building, Kaula Park, Sangrur through its Branch Manager.

2.             IFFCO TOKIO General Insurance Company Limited, Registered Office: IFFCO Sadan, C-1, District Centre, Saket, New Delhi through its Managing Director.

                                                        ..Opposite parties.

 

 

For the complainant    :       Shri J.S.Sahni, Adv.

For Opp.parties          :       Shri Darshan Gupta, Adv.

 

 

Quorum:    Sukhpal Singh Gill, President

                Sarita Garg, Member

               

 

Order by : Sukhpal Singh Gill, President.

 

1.             Shri Sushil Kumar, complainant (referred to as complainant in short) has preferred the present complaint against the opposite parties (referred to as OPs in short) on the ground that the complainant availed the services of the OPs by  taking a Family Health Protector policy number 52560729 from the OPs for the period from 15.12.2015 to 14.12.2016, which was subsequently renewed vide policy number 52714681 for the period from 15.12.2016 to 14.12.2017 and for this purpose he paid the premium to the tune of Rs.10,491/- and Rs.10,537/-, respectively and the sum insured was for Rs.2,00,000/-.  The case of the complainant is that he suffered pain in his chest as such he was taken to Singla Nursing Home and after some medical tests, he was taken to Hero DMC Institute and Hospital Ludhiana on 28.11.2016 and after thorough check up, the doctor of hospital told the complainant that his condition was critical and requires immediate bypass surgery of heart and the surgery was conducted on 2.12.2016, as such the complainant remained admitted in the hospital from 28.11.2016 to 10.12.2016 and during this treatment the complainant spent about Rs.3,26,000/- on his treatment.  Further case of the complainant is that after discharge from the hospital, the complainant submitted all the relevant documents/bills to the OPs for reimbursement, but the OPs repudiated the claim of the complainant vide letter dated 16.5.2017, which is said to be wrong and illegal.  Thus, alleging deficiency in service on the part of the OPs, the complainant has prayed that the Ops be directed to pay to the complainant the claim amount of Rs.3,26,000/- along with interest @ 18% per annum and further claimed compensation and litigation expenses.

 

2.             In reply filed by the OPs, legal objections are taken up on the grounds that the complaint is wholly misconceived, groundless and unsustainable in law, that the complaint is baseless and flagrant abuse of process of law, that the complainant has not come to the Forum with clean hands and that intricate questions of law and facts are involved in the present case.  On merits, it is admitted that the complainant was issued a medi claim insurance policy for Rs.2,00,000/- for the period from 15.12.2015 to 14.12.2016 for Rs.2,00,000/- as per the terms and conditions of the policy.  It is admitted that a cashless request was received by the OPs on 29.11.2016 from Dayanand Medical College and Hospital Ludhiana regarding the complainant and on receipt of the cashless request, the OPs sent a discrepancy letter on 29.11.2016 to Dayanand Medical College and Hospital to provide requisite information in order to process the cashless claim and on scrutiny of the submitted information/documents, it was observed that the ‘liability of cashless claim’ cannot be ascertained at this time and detailed evaluation is required in this cashless claim, as such the claim of the complainant was denied. It is further averred that after receipt of the documents and on scrutiny, it was observed that some requisite documents/information was required, which was sought vide letters dated 23.1.2017, 7.2.2017 and 22.2.2017, but the same were not submitted by the complainant. It is further averred that after perusal of the documents, it was observed that it was a case of hypertension, diabetes, mellitus type-II, coronary artery disease with acute coronary syndrome, double vessel disease, LVEF=22%, moderate MR, severe LV systolic Dysunction, mild plaque at CCA, LCCA & LCB and he underwent total arterial complete revascularization with bilateral IMA OPCABG X3. It is further averred that coronary artery disease, CAD has a direct co-relation with hypertension and there is two years waiting period from disease aggravating out of hypertension and diabetes in the policy, therefore, it is averred that the claim is not payable under clause 5(b) of the insurance policy, as such it is stated that the claim has rightly been repudiated vide letter dated 16.5.2017.  The other allegations levelled in the complaint have been denied in toto.    

 

3.             The learned counsel for the complainant has produced Ex.C-1 to Ex.C-27 copies of documents and affidavit and closed evidence. On the other hand, the learned counsel for the OPs has produced Ex.OP-1 affidavit along with annexure R-1 to Annexure R-10 and closed evidence.

 

4.             We have carefully perused the complaint, version of the opposite parties and evidence produced on the file and also heard the arguments of the learned counsel for the parties. In our opinion, the complaint merits dismissal, for these reasons.

 

5.             It is an admitted fact between the parties that the complainant was insured with the Ops under medi claim insurance policy for Rs.2,00,000/- by paying the requisite premium for the period from 15.12.2015 to 14.12.2016.  It is further an admitted fact that the complainant suffered pain and as such he was taken to Hero DMC Heart Institute and Hospital Ludhiana, where he remained admitted from 28.11.2016 to 10.12.2016, where he spent an amount of Rs.3,26,000/- on the heart treatment. But, the grievance of the complainant is that the OPs repudiated the claim being not payable on the ground that the claim of the complainant does not fall under exclusion clause 5(b), which provides that “what is not covered: 5(b): Any expenses on disease aggravated by Diabetes and/or Hypertension, incurred in the first two years of operation of the insurance cover. However, if these diabetes and/or hypertension is/are under pre-existing conditions at the time of first proposal then these will be falling under exclusion 2(a) and will be covered after 48 months of continuous coverage’s with us”.  It is an admitted fact on record that the complainant suffered problem of coronary artery disease within the very first year of the policy, as the policy in question was taken for the period from 15.12.2015 to 14.12.2016 and the complainant suffered problem on 28.11.2016, as such, we feel that the treatment taken by the complainant is not covered under the policy in question and further find that the claim of the complainant has rightly been repudiated vide letter dated 16.5.2017, Ex.C-2.  This fact is also further supported by the affidavit of Dr. D.P. Lamba, MBBS, Annexure R-10, wherein he has clearly stated that hypertension is a significance risk factor for coronary artery disease (CAD) as CAD has a direct co-relation with hypertension.

 

6.             Accordingly, in view of our above discussion, we find no merit in the complaint and the same is , therefore, dismissed. However, the parties are left to bear their own costs. A copy of this order be issued to the parties free of cost. File be consigned to records.

                        Pronounced.

                        December 15, 2017.

                                                        (Sukhpal Singh Gill)

                                                                President

 

                                                             

                                       

                                                                (Sarita Garg)

                                                                    Member