MEDITEK TPA SEVICES. V/S MANJU YADAV - Consumer Court Case

Delhi

East Delhi

CC/643/2013

MANJU YADAV - Complainant(s)

Versus

MEDITEK TPA SEVICES. - Opp.Party(s)

06 Aug 2018

ORDER

DISTRICT CONSUMER DISPUTE REDRESSAL FORUM, EAST, Govt of NCT of Delhi

CONVENIENT SHOPPING CENTRE, 1^st FLOOR, SAINI ENCLAVE, DELHI 110092

Consumer complaint no 643/2013

Date of Institution 27/07/2013

Order reserved on 06/08/2018

Date of Order 09/08/2018

In matter of

Mrs Manju Yadav, adult

w/o- Mr Manoj Yadav

R/o- WZ- 178, Village Shakurpur

New Delhi 110034……………………………………...…………….Complainant

1-M/s E-Meditek TPA Services Pvt Ltd.

Plot no. 577, Udyog Vihar Phase V,

Gurgaon 122016, Haryana

2-United India Insurance Co. Ltd.

RO- G-22, Vardhman Complex, Janak Market

A-2B, Janak Puri, New Delhi 110058 ……………….…………..Opponents

Complainant’s Advocate Rajesh Kumar Sharma

Opponent 1 & 2 Advocate Ms Richa Jindal & Mohd. Furkhan

Quorum Sh Sukhdev Singh President

Dr P N Tiwari Member

Mrs Harpreet Kaur Member

Order by Dr P N Tiwari Member

Brief Facts of the case

Complainant purchased Family Health Optima Insurance (Floater) policy from M/s Star Health and Allied Insurance Co. Ltd. for herself, her husband and two children having its tenure from 20/10/2010 to 19/10/2011 vide policy no. P/161118/01/20-11003055 having sum assured a sum of Rs one lacs (ex CW1/1). It had been stated that complainant opted Family Medicare policy from United India Insurance Co. / OP2 for herself and her two children having its tenure from 20/10/2012 to 19/10/2013 having sum assured 3 lacs as first year policy (Ex CW1/2).

Complainant got severe pain in upper abdomen so was taken to Maharaja Agrasen Hospital, Delhi on 19/03/2013 in Emergency Room (Ex CW1/3). After examination and investigations, it was told that complainant had to undergo operation as she had Gall Bladder stone, so was admitted and operated and complainant was discharged on 21/03/2013 (Ex CW1/4). When no response of cashless was received, complainant paid entire hospital bill of Rs 40,000/-. Complainant applied for reimbursement after submitting claim form 26/03/2013 (Ex CW1/5).

It was stated by the complainant that OP1/TPA asked for some previous treatment documents, continuity of insurance policy from Star Health vide claim no. 122031304161 on dated 20/05/2013 (Ex CW1/6). Even after submission of required additional documents, OP1 did not clear the claim nor informed accordingly, but received repudiation letter (Ex CW1/7) on dated 05/06/2013 giving reason as “Claim repudiated under exclusion clause 4.2 and 4.3 giving explanation as –

“Any disease other than those stated in clause 4.3, contacted by the insured person during the first 30 days from the commencement date of the policy. The condition 4.2 shall not, however apply in case of the insured person having been covered under any health insurance policy or group insurance scheme with the company for a continuous period of preceding 12 months without any break.”

Complainant wrote letters and visited personally, but OP1 did not consider her version. Aggrieved by the deficient act of OP1 and OP2, filed this complaint claiming refund of treatment cost Rs 40,000/- with 24% interest on it. She also claimed compensation Rs 50,000/- for mental harassment and agony with litigation charge Rs 15,000/-.

On receiving notices OP 1 & OP2 put their appearance and submitted jointly written statement and denied all the allegations of deficiency on their part. It was stated that complainant had taken policy from OP2 vide policy no. 041381/48/12/06/00000348 from 20/10/2012 to 19/10/2013 for complainant and her two children as a Family Medicare policy (on record) and had accepted by the OP2, but as claim for Cholilithiasis came in first year, so after proper verification of claim documents, claim was rightly repudiated under exclusion clause 4.2 and 4.3.

OP submitted explanation to the exclusion clauses as – “Any disease other than those stated in clause 4.3, contacted by the insured person during the first 30 days from the commencement date of the policy. The condition 4.2 shall not, however apply in case of the insured person having been covered under any health insurance policy or group insurance scheme with the company for a continuous period of preceding 12 months without any break.”

OP also took references from citations justifying their repudiation based on as –

OIC vs Sony Cheriyan, (1999) 6 SCC 451,
NIC vs Laxmi Narayan Dutt, (2007) 258 SC
Suraj Mal Ram Niwas Oil Mills (P) Ltd vs UIIC, 2011 CTJ 11 SC.

As claim for Gall Bladder Stone removal was reported in first year of policy tenure, so claim was repudiated as per exclusion clause, so there was no deficiency in services of OP and complaint may be dismissed.

Complainant submitted her rejoinder where she denied replies submitted by OP as wrong and incorrect. It was stated that all correct facts and evidences were submitted with her complaint. She also submitted her evidences on affidavit where she reaffirmed herself on oath that all her evidences were on record. It was stated that OP had not considered her policy tenure and repudiated her genuine claim.

OP submitted their evidences through Ms Angila Samad, working as Deputy Manager with OP2. It was stated that the repudiation of claim was in first year and was rightly repudiated under exclusion clause 4.2 and 4.3 of policy terms and conditions. It was submitted that OP1/TPA had scrutinized all the claim documents submitted by complainant and found that claim was reported in first year of its inception so claim was rightly repudiated. OP also submitted their written arguments and taken on record.

Arguments were heard from both the Ld counsel and after perusal of records, order was reserved. We have gone through all the facts and evidences on record. It was seen that the complainant and her husband were insured earlier with Star Health Insurance Co. from 2010 to 2012 for two years under Floater mediclaim policy.

Thereafter complainant opted present Family Medicare Policy for herself and her two children from present OP / United Insurance Co. with sum assured 3 lacs. As the claim was reported for Acute Cholilithiasis as complainant was admitted for acute pain in upper abdomen as per treating doctor’s letter (Ex CW1/8) and after investigation, she was diagnosed for Cholilithiasis (GB Stone) and underwent Laproscopic Cholicystectomy. It was also observed from the discharge summery (Ex CW1/4) where it was written as “NO HISTORY OF ANY CHRONIC ILLNESS” and in present case it was an acute condition where single gall bladder calculus was removed.

It was also observed that complainant had submitted proper reply to OP1 query pertaining to the continuity of policy duration and claim free tenure. Under this pretext, though complainant had ported to present OP from Star Health and thereafter complainant had acute pain in her upper abdomen which was diagnosed as case of single Gall Bladder Stone. There was no past history of pain or diagnosis.

It was also analysed about the cause of Acute Pain in upper abdomen which was due to single Gall Bladder stone. To sustain this view of types of GB Stone, it was seen in medical text as under –

“They aren’t really stones. They're pieces of solid material that form in the gallbladder, a small organ located under the liver. As there are two types of Gall Bladder stones arising from Bile juice are silent and do not represent any complications till obstruct common bile duct and during this phase acute pain occurs whereas a person remains symptom free till diagnosis. One might not even know that when they block a bile duct, causing

The two main kinds of G B Stones are present: