DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II
Udyog Sadan, C-22 & 23, Qutub Institutional Area
(Behind Qutub Hotel), New Delhi-110016.
Case No.264/2011
Sh. Subhash Goyal
R/o 111, Pocket 3, SFS Flats,
Ground Floor, Sector-11,
Dwarka, New Delhi-110075 ….Complainant
Versus
1. M/s Medsave Healthcare (TPA) Ltd.
F-701 A, Lado Sarai,
Mehrauli, New Delhi-110030
2. Oriental Insurance Co. Ltd.
through its branch manager
C-30, Sector-II,
Noida, Gautam Budh Nagar,
U.P.-201301 ……Opposite Parties
Date of Institution : 27.07.11 Date of Order : 22.09.16
Coram:
Sh. N.K. Goel, President
Ms. Naina Bakshi, Member
O R D E R
Briefly stated, the case of the Complainant is that he alongwith his family was under regular mediclaim coverage from insurance company and the OP had approached him for renewal of the policy and assured him that the policy will be renewed on the same terms and benefits. He agreed to go with the OP for renewal of the policy and the policy No.272500/48/20/672 was issued and renewed in 2010; that the policy was in continuation since 2007 although it was with other insurance companies prior to its renewal by the OP and the policy was without any break. It is stated that the details of his previous policies were written on the cover note of the insurance policy in question. On 08.05.11 his wife was hospitalized due to acute pain in the stomach and during the course of her hospitalization a claim was lodged with the OP’s TPA department who was pleased to credit a sum of Rs,.30,000/- in favour of the hospital authorities on 09.05.11 and 13.05.2011, although at the time of discharge when the claim for balance amount was raised, OPs due to flimsy reasons did not pay the balance amount; rather they took back Rs.30,000/- which forced him to borrow money from his friend to pay the hospital amount. He approached the TPA but the OP repudiated the claim on the ground that the Complainant had not disclosed about the previous policies to them while taking the policy in question. His wife was first time admitted and treated for this illness and there was no history for this illness. The Complainant has stated that OPs in the month of March 2011 had settled the claim as raised due to illness of his wife and no objection qua the same was raised by them at that point of time. The Complainant has stated that he had given all the details of his previous polices and the same were written on the cover note issued by the OPs and the Complainant has been given no claim bonuses on his previous policies by the OPs. The repudiation of the claim is unreasonable, illegal and arbitrary and is liable to be revoked. The Complainant filed representation on 04.06.11 but no response was received from the OPs. He contacted the OPs several times to settle the claim but OPs failed to settle his claim. Hence pleading deficiency in service on the part of OPs the complaint has been filed with the following reliefs:-
- Direct the OPs to pay an amount of Rs.86,662/- to the Complainant being the claim amount.
- Direct the OPs to pay Rs.50,000/- as compensation for loss and injury and inconvenience caused by the negligence by the OPs and Rs.50,000/- against mental agony caused to the Complainant.
- Direct the OP to pay Rs.10,000/- to the Complainant by way of the cost.
OP-2 Oriental Insurance Co. Ltd. in the written statement has inter-alia stated that as per the prescription of Dr. Animesh Arya dated 21.04.11 they came to know that the insured was having this illness for the last 1 and 1/2 year. Therefore, the disease was contracted prior to inception of policy. Therefore, the disease for which treatment was received was a pre-existing illness. Hence, exclusion clause No.4.1 of the policy excluded all pre-existing illnesses from the scope of the policy and, therefore, the claim in question became inadmissible. They repudiated the claim under clause 4.1 of the policy issued by the OP. The Complainant is not entitled for reimbursement of the amount and TPA had rightly repudiated the claim and there is no deficiency in services in terms of the provisions of the Consumer Protection Act. OP has prayed for dismissal of the complaint with costs.
Complainant has filed rejoinder to the written statement of OP and stated that the policy was renewed by the OP in 2010 and the policy was in continuation since 2007. Therefore, the exclusion under clause 4.1 of the policy issued by the OP does not come as he was previously insured and the OP had agreed to avail all the benefits as he would have got had he not shifted to their insurance company.
Complainant has filed his own affidavit in evidence while affidavit of Sh. S. S. Jaggi, Divisional Manager has been filed in evidence on behalf of the OP.
Written arguments have been filed on behalf of the parties.
We have heard the arguments of the Counsel for the Complainant and have also gone through the file very carefully.
It is not in dispute that the Complainant had an insurance policy with OP in the year 2010. The Complainant changed the insurance company in the year 2010. According to the complainant and not specifically denied by the OP the details of the previous mediclaim policies taken by the complainant were given by the OPs while taking the policy in question from them. We find substantial weight in this submission made on behalf of the complainant. A carbon copy of the No. 541991 dated 14.6.2010 has been filed on the record which we mark as mark AA for the purposes of identification. It is mentioned in the said document that the policy in question was a renewal policy of policy No. A41-0020841.000-01 of Chalamandalam M.S.G.I. Co. Ltd., DO NOIDA and the complainant was also given discount of 10% on the insurance premium. This document goes a long way to prove that the policy in question was issued by the OP-2 to the complainant in continuation of the earlier policy/policies taken by the complainant from the other insurance companies. Therefore, it cannot be successfully contended on behalf of the OP that the policy in question was the first policy. It is a matter of great sorrow that while taking business from the innocent persons, agents/officials of the insurance companies give every kind of promise but while issuing the claim amount they take unnecessary excuses. When the policy in question was not the first policy and was in continuation of the previous policies, the OPs were not justified in repudiating the claim of the complainant on the ground that his wife had been suffering from the illness in question for the last 1 ½ years and, hence, it was a pre-existing disease or that exclusion clause 4.1 was applicable to the facts of the present case. Secondly, as submitted by the complainant and not specifically denied by the OPs, earlier claim of the complainant filed with the OPs in respect of the treatment received by the wife of the complainant in March 2011 had been settled by the OPs. Copy of letter dated 15.4.2011 has been filed on the record which we mark as mark BB for the purposes of identification. Vide this letter, OP-1 had sent cheque No. 503445 for an amount of Rs. 4500/- towards reimbursement of the claim submitted by the complainant. This fact also proves that the earlier claim lodged by the complainant with the OPs had been settled by the OPs. Therefore, on this ground also the OPs were not justified in repudiating the claim in question of the complainant. Therefore, we hold OP-2 guilty of grave deficiency in service and also unfair trade practice.
In view of the above discussion, we allow the complaint and direct the OP No. 2 to pay Rs.86,662/- towards claim amount in question along with interest @ 7% p.a. from the date of filing of the complaint till realization and Rs. 35,000/- as compensation for mental agony and harassment caused to the Complainant and his wife and Rs.5,000/- towards cost of litigation.
The order shall be complied within 30 days of receipt of copy of this order failing which OP-2 shall become liable to pay interest @ Rs. 10% per annum on the amount of Rs.86,662/- from the date of filing of the complaint till the date of 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.
(NAINA BAKSHI) (N.K. GOEL) MEMBER PRESIDENT
Announced on 22.09.16.
Case No. 264/11
22.9.2016
Present – None.
Vide our separate order of even date pronounced, the complaint is allowed. OP-2 is directed to to pay Rs.86,662/- towards claim amount in question along with interest @ 7% p.a. from the date of filing of the complaint till realization and Rs. 35,000/- as compensation for mental agony and harassment caused to the Complainant and his wife and Rs.5,000/- towards cost of litigation. The order shall be complied within 30 days of receipt of copy of this order failing which OP-2 shall become liable to pay interest @ Rs. 10% per annum on the amount of Rs.86,662/- from the date of filing of the complaint till the date of realization. Let the file be consigned to record room.
(NAINA BAKSHI) (N.K. GOEL) MEMBER PRESIDENT
