DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II
Udyog Sadan, C-22 & 23, Qutub Institutional Area
(Behind Qutub Hotel), New Delhi-110016
Case No.154/2012
Shri Balram Sharma (Senior Citizen)
1685, Sector-4, 72 years Old
Gurgaon, Haryana. ….Complainant
Versus
- Medsave Healthcare (TPA) Ltd.
F-701A, Lado Sarai, Behind Gold Course
New Delhi-110030.
- United India Insurance Co. Ltd.
24, Whites Road,
Chennai-600014.
- Indian Spinal Injuries Centre
Sector C, Vasant Kunj,
New Delhi-110070.
….Opposite Parties
Date of Institution : 23.04.12 Date of Order : 31.03.18
Coram:
Sh. N.K. Goel, President
Ms. Naina Bakshi, Member
ORDER
The case of the complainant, in brief, is that he had taken mediclaim insurance policy from OP-2 two years back and the current policy number is 110300/48/10/14/00000762 and OP-2 has appointed OP-1 as third party administrator to deal with the claim. In later part of June, 2011 complainant started feeling some heaviness in his lower part of body and got the treatment from Medanta City Hospital, Gurgaon. When the things did not improve, he approached OP-3 who diagnosed the disease as Dorsal Myelopath with Pararesis advised operation of the same. Complainant was admitted in OP-3 on 07.10.2011 and discharged on 11.10.2011; he immediately intimated OP-1 but cashless claim was not approved by OP-1 and OP-2. After discharge, he again submitted his claim before OP-1 on 18.11.2011 with all documents and medical records etc. but claim has not been decided by OP-1 and OP-2 so far. According to him, he spent a sum of Rs.1,25,664/- along with medication charges of Rs.4,334/-in OP-3 hospital besides the other money detailed in para-7 of the complaint in various other hospitals including Medanta City Hospital. Complaint states that none payment of cashless claim itself amounts to deficiency in services and thereafter non deciding of the claim by OP-1 itself amounts to deficiency in service and even repudiation of the cashless claim on the ground of pre-existing disease is wrong because the said disease never existed to the complainant and it occurred in the month of June, 2011. Hence, pleading deficiency in service on the part of the OPs, the complainant has filed the present complaint for issuing directions to OP-1 and OP-2 as follows:-
- To pay Rs.1,58,613/- with interest @ 18% per annum;
- To pay Rs.7,500/- with interest @ 18% per annum which the complainant has paid towards medication and consultation charges;
- To direct the reimbursement of entire charges which will occur in future pertaining to the present disease;
- To impose cost of Rs.2 lakhs upon the OP no. 1 and 2 towards harassment, compensation etc.
- To pay Rs.21,000/- towards litigation charges to the complainant;
OP-1 and OP-3 have been proceeded exparte.
OP-2 in the written statement has inter-alia pleaded that the complainant was holding a mediclaim policy bearing No. 110300/48/10/14/00000762 for the period of 01.01.2011 to 31.12.2011 and that the complainant was bound by the terms and conditions of the policy signed by him; that his case fell under the Exclusion Clause 4.1 of Health Insurance Policy which reads as under:-
“4.1 All diseases / injuries which are pre-existing when the cover incepts for the first time for the purposed of applying this condition, the date of inception of the initial mediclaim policy taken from any of the Indian insurance companies shall be taken. Provided the renewal have been continuous and without any break, however this exclusion will be deleted after 3 consecutive continuous claim free policy years, provided there was no Hospitalisation for the pre-existing ailment during these three years of insurance.”
According to OP-2, as per the discharge summary of the hospital dated 10.11.2011, it is mentioned that the complainant had the past history of HTN for 12 years on regular medication which fact was not disclosed by the complainant to the OP while taking the policy. It is further submitted that pre and post hospitalisation treatments are not covered under the term and conditions of the policy. It is prayed that the complaint be dismissed.
Complainant has filed a rejoinder.
Complainant has filed his own affidavit in evidence. On the other hand, affidavit of Shri Satish Sharma, Deputy Manager has been filed in evidence on behalf of OP-2.
Written arguments have been filed on behalf of the parties.
We have heard the oral arguments on behalf of the complainant and have also gone through the file very carefully.
The only question to be decided is, whether the suppression of fact with regard to the complainant having HTN history for the last 12 years and not disclosing of the same to OP-2 at the time of taking the initial policy amounts to suppression of material fact with regard to pre-existing disease and hence OP-1 and OP-2 were justified in repudiating the claim in question of the complainant by invoking the provisions of clause 4.1 of the policy in question.
As pleaded in the complaint and proved from the medical record (copy Ex. CW-1/2) the complainant had been diagnosed as the case of “Dorsal Spinal Cord impression Dorsal Myelopathy at D10-11, D11-12 with paraperesis” from which he was suffering for the last 3 months. He had a history of HTN for last 12 years. Now the only thing in this regard which is to be seen is whether the HTN had/has anything to do with dorsal spinal cord care disease.
Myelopathy means “dysfunction of the spinal cord”. Myelopathy is a result of untreated stenosis of the spinal canal that exerts prolonged pressure on the spinal cord….Myelopathy commonly occurs in the cervical region of the spine and only occasionally in the thoracic region.”
OP-2 has not brought any evidence on the record to show that the HTN and said disease have any interconnection.
Therefore, we are of the considered opinion that the bar contained in clause 4.1 of the terms and conditions of the policy in question did not apply to the facts of the present case and OP-2 committed gross deficiency in service in repudiating the claim of the complainant.
However, we agree with OP-2 that the pre and post hospitalisation treatment are not covered under the terms and conditions of the policy in question.
Keeping in view the facts discussed hereinabove, we allow the complaint and direct OP-2 to pay sum of Rs.1,25,664/- along with @ 6% p.a. interest from the date of filing of the complaint till realization and Rs.25,000/- towards harassment and cost of litigation etc. to the complainant within 30 days from the date of receipt of copy of this order failing which the OP-2 shall become liable to pay interest @ Rs.9% per annum on the amount of Rs.1,25,664/- to the complainant 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 31.03.18.
