DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II
Udyog Sadan, C-22 & 23, Qutub Institutional Area
(Behind Qutub Hotel), New Delhi-110016.
Case No. 612/2009
Bal Kishan Goel,
C/o Mahadev Video Coverage
1926/147, Main Road Tri Nagar
Delhi - 110035 ….Complainant
Versus
1. M/s Reliance General Insurance Co. Ltd.
(Anil Dhirubahi Ambani Group)
570, Naigaurn Cross Road ,
Next to Royal Industrial Estate,
Wadala (W) Mumbai – 40031.
2. M/s Medi Assist India (P) Ltd.
F-2, Kailash Plaza, 2nd Floor,
H-252, Sant Nagar,
New Delhi-110065 .…Opposite Parties
Date of Institution : 04.08.2009 Date of Order : 24.09.2016
Coram:
Sh. N.K. Goel, President
Ms. Naina Bakshi, Member
O R D E R
The case of the complainant, in nutshell, is that he purchased mediclaim policy bearing no. 282530035222 from the OP and the policy was valid from 07.01.2009 to 06.01.2011. In February, 2009, he was having some problem in his right ear and consulted Dr. Anil Kr. Monga, ENT specialist who advised the complainant for surgery of his ear, namely, Thmpanoplsty under GA. The complainant got himself admitted in Sir Ganga Ram Hospital on 9.3.2009 and Dr. Anil K. Monga successfully conducted the surgery and the complainant was discharged on 10.3.2009 after paying an amount of Rs. 47,893/- towards medical expenses in cash. The complainant contacted the OP but the OP rejected his claim on the ground that the said disease was six months old. Thereafter, the complainant contacted Dr. Anil K. Monga who issued a letter stating therein that the six months period of disease may be read as 3 weeks but the OP again rejected the claim of the complainant. The complainant served OP with the legal notice dated 6.7.2009 but in vain. Hence, pleading deficiency in service on the part of the OP the complainant has filed the present complaint for issuing direction to the OP to pass the claim of Rs. 47,893/-, to pay Rs. 50,000/- as compensation for mental agony and harassment by mal-practicing against the norms of the market and to award exemplary costs to the complainant.
Thereafter, OP was proceeded exparte. The exparte evidence was filed and vide order dated 5.7.2011, our Predecessors allowed the complaint.
OP filed FA-547/11 before the State Commission, Delhi who vide order dated 3.9.2013 set aside the order dated 5.7.2011 and remanded back to this forum thereby suo-motto making the Reliance General Insurance Company a Party along with M/s Medi Assist India Pvt. Ltd. Accordingly, Reliance General Insurance Company has been arrayed as OP-1 and M/s Medi Assist India Pvt. Ltd. as OP-2.
OP-1 in the written statement has inter-alia stated that the complainant being in the first year of the policy was admitted in Sir Ganga Ram Hospital for the treatment of Right CSOM (Chronic Suppurtive Otitis Media); that the complainant opted for cashless facility and a request was sent from the Hospital wherein it was clearly mentioned that the duration of ailment was “from past six months”; that the admission was during the 3rd month of the Policy Cover; that the cashless facility was rejected on the ground that the ailment was pre-existing which fell prior to the inception of the policy. It is stated that after the receipt of the letter from Dr. Anil K. Monga that the duration of the disease had been mentioned as six months due to inadvertent mistake and the same may be ignored while considering the claim of the complainant the investigation report stated that the ailment had a history of six months as per the Operative Notes, indoor case papers and the discharge summary of the insured and, thus, the claim of the insured was also repudiated on the ground of pre-existing disease and non-disclosure of the same at the time of inception of the policy. It is further stated that in order to confirm the details of the case a letter dated 8.7.2009 was sent to Dr. Anil K. Monga requesting him to clarify the doubt; that in answer to the said letter, Dr. Anil K. Monga stated “I confirm my notes given to you. Discretion is yours”. Hence, taking into consideration the various documents and the report of the insured the OP had rightly repudiated the claim of the insured as per non-disclosure of the pre-existing disease. Other averments made in the complaint have been denied. Hence, it is prayed that the complaint be dismissed.
Complainant has filed rejoinder wherein he has reiterated the averments made in the written statement of OP-1.
Vide a statement made on 6.5.2015 by the counsel for the complainant, the complaint against M/s Medi Assist India (P) Ltd. has been dismissed as withdrawn.
Complainant has filed his own affidavit in evidence. On the other hand, affidavit of Sh. Mohit Raj Nagar, Deputy Manager Legal has been filed on behalf of the OP.
Written arguments have been filed on behalf of the parties.
We have heard the counsel for the parties and have also carefully gone through the file.
Complainant has reiterated the averments made in the complaint. In the discharge summary (copy Annex. C) filed on behalf of the complainant, it is mentioned as follows:
“History: C/o reduced hearing x 6 months
No c/o ear discharge, tinnitus
Past History: Patient diabetic, hypothyroid, taking Eltroxin, OHS
No h/o HT
Physical Finding:
Central perforation (Right Ear)
Oral Cavity, propharynx – WNL”
This medical document proves that the complainant had been suffering from the said disease for the last six months. Discharge summary is dated 10.3.2009. However, Dr. Anil K. Monga wrote a letter to M/s Medi Assist India (P) Ltd on 12.3.2009 stating therein that he had inadvertently written the history of the illness as six months whereas it was actually a short history of 3 weeks following a cold. Copy of this letter filed by the complainant is Annex. E. Therefore, it is crystal clear that the doctor had changed the period of the disease.
Copy of the policy in question has been filed as Ex. R-1 which contains Policy Exclusions Clause in which it is inter-alia stated that the OP Company shall not be liable to make any payment for any claim directly or indirectly caused by, based on, arising out of or howsoever attributable to pre-existing diseases/illnesses/ injuries/conditions which are pre-existing when the cover incepts for the first time. Policy Exclusions Clause also contained Clause 7 which exempts the OP Company to make payment in the following circumstances:
“7. Routine medical, eye and ear examination, cost of spectacles, laser surgery, contract lenses or hearing aids, vaccinations, issue of medical certificates and examinations as to suitability for employment of travel.”
It clearly means that the OP Company is exempted from making any payment in respect of the ear examination and not in the case of surgery in the ear. Had it been so, the OP would have certainly clarified this fact in Clause 7 of the Policy Exclusions Clause. Therefore, without going into any discussion on whether Dr. Anil K. Monga was or was not justified in writing letter (Copy Annex. E) to the TPA of the OP Company, we find that the case of the complainant is not covered by the Policy Exclusions Clause.
In view of the above discussion, we hold that the OP Company committed deficiency in service while rejecting the claim in question of the complainant. We, therefore, allow the complaint and direct the OP Company to pay Rs. 47,893/- along with interest @ 6% p.a. from the date of filing of the complaint till realization towards the claim in question and Rs.15,000/- in lumpsum towards compensation for mental agony and harassment and cost of litigation to the complainant within one month from the date of receipt of copy of this order failing which the OP Company shall become liable to pay the above stated amount of Rs. 47,893/- along with interest @ 9% 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 24.09.16.
(NAINA BAKSHI) (N.K. GOEL) MEMBER PRESIDENT
Case No. 612/09
24.09.2016
Present – None.
Vide our separate order of even date pronounced, the complaint is allowed. The OP Company is directed to pay Rs. 47,893/- along with interest @ 6% from the date of filing of the complaint till realization towards the claim in question and Rs.15,000/- in lumpsum towards compensation for mental agony and harassment and cost of litigation to the complainant within one month from the date of receipt of copy of this order failing which the OP Company shall become liable to pay the above stated amount of Rs. 47,893/- along with interest @ 9% p.a. from the date of filing of the complaint till realization. Let the file be consigned to record room.
(NAINA BAKSHI) (N.K. GOEL) MEMBER PRESIDENT
