DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II
Udyog Sadan, C-22 & 23, Qutub Institutional Area
(Behind Qutub Hotel), New Delhi-110016.
SENIOR CITIZEN
(71 Yrs. )
Case No.221/2015
Sh. Gurbakash Singh Chawla
S/o Shri Sat Kartar Singh
R/o C-1-1517, Vasant Kunj,
New Delhi-110070 ….Complainant
Versus
1. Medsave Healthcare (TPA) Ltd.
F-701A, Lado Sarai, Mehrauli,
New Delhi-110030
2. United India Insurance Co. Ltd.
10203, 3rd Floor,
Jamna House,
Padam Singh Road
New Delhi-110005 ……Opposite Parties
Date of Institution : 20.08.15 Date of Order : 09.02.17
Coram:
Sh. N.K. Goel, President
Ms. Naina Bakshi, Member
O R D E R
Complainant’s case, in short, is that he was admitted in the Fortis Hospital, Vasant Kunj, New Delhi. from 30.05.15 to 31.05.15 but the OP No.1 did not pay Rs.36208/- to him towards his medical claim. All the papers regarding TPA for cashless payment were forwarded to the OPs for payment but no payment has been made till date. The Complainant has requested for payment of Rs.36208/- and damages to him.
OP No.1 has been proceeded exparte vide order dated 29.03.16.
OP No.2 in the written statement has inter-alia stated that they had informed to the Complainant vide letter dated 06.08.15 that the Complainant is not entitled to the cashless facility as the line of treatment does not justify for hospitalization; that the Complainant was further advised by the OP No.1 to submit the hospitalization papers for reimbursement and the claim would be settled after investigation and gathering more information, if found admissible as per the policy terms and conditions. The claim of the Complainant was examined as per the documents submitted by the Complainant in the office of OP No.1 and thereafter the claim was repudiated by the competent authority vide letter dated 13.07.15 which was on the basis of discharge summary which shows that the Complainant was suffering from hypertension, CAD-DVD, PTCA, TO LAD (May 2013) with proteinuria x iyear admitted for Kidney biopsy. The biopsy was done primarily for investigation and evaluation purpose and it falls under the policy terms and conditions exclusion clause No.4.1 which states that:
“4.1
All the diseases/injury which are pre-existing when the cover incepts for the first time. For the purpose of applying this conditions, the date of inception of the initial mediclaim policy taken from any of the Indian Insurance Company shall be taken provided the renewals have been continuous and without any break. However, this exclusion will be deleted after 3 consecutive continuous claim free policy years, provide there was no hospitalization for there existing ailment during these 3 years of insurance.”
It is submitted that as per clause 4.1 of the aforesaid policy the claim was repudiated by the competent authority as it fell under the category of pre-existing clause 4.1 of the policy. OP No.2 has prayed for dismissal of the complaint.
Complainant has filed a rejoinder to the written statement of OP No.2. It is stated as follows:-
“The complainant is insured by opposite party since November, 2008 and has paid all yearly premium well in time and got all the nine polices renewed during last 8 years. There is no default in payment or there has been no late payment of the premium, so the opposite party is bound to pay the claim made by the Hospital, during hospitalization of the complainant.”
Complainant has filed his own affidavit in evidence. On the other hand, affidavit of Dr. D. K. Sharma, Senior Development Manager has been filed in evidence on behalf of OP No.2.
Written arguments have been filed on behalf of the parties. We have heard the arguments on behalf of the Complainant and OP No.2 and have also gone through the file very carefully.
Copy of the Insurance Policy in question has been filed on the record which according to the OP is exhibit RW1/C. The previous policy number/ details have been mentioned therein as Policy No. 04050048131400003439 valid from 27.11.2013 to 26.11.2014. This fact recorded in the insurance policy in question itself fortifies the version of the Complainant that he had been getting the insurance policy from the OP since November, 2008 without any break or any default. Clause 4.1 which deals with exclusion provides that the OP company shall not be liable to make any payment under this policy in respect of expenses whatsoever incurred by any insured person in connection or in respect of particular existing condition. We immediately say that the case of the complainant was not covered under exclusion clause 4.1. of the policy in question and ,therefore, the repudiation of the claim by the OP was against the terms of the policy and hence amounted to deficiency in service on its part.
Therefore, we hold that the OP committed serious deficiency in service while repudiating the claim of the Complainant.
In view of the above discussion, we allow the complaint and direct the OP 2 Insurance Company to pay Rs. 36,208/- to the Complainant within a period of 30 days from the date of receipt of copy of this order failing which OP 2 shall become liable to pay this amount to the complainant along with interest @ of 7% p.a. from the date of filing of the complaint till realization.
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 09.02.2017
