ORDER

19.04.2024

Sh. Sanjay Kumar, President

1. In brief facts of the present case are that the complainant had purchased the Family Mediclaim Insurance Policy since several years & super topup Policy since 2010 through its agent ( Agent Code AGD0081485) of OP2 for  a sum insured to the tune of Rs. 2 Lakhs and super top up for Rs.3,00,000.00. It is stated that at the time of purchasing the above mentioned policy complainant was assured by the agent of OP2 that he above mentioned policy is a very good policy and helpful to your medically expenses bill. It is stated that on the assurance given by the official of OP1 complainant bought the above mentioned Medical Policy. The official of OP assured that “PRE HOSPITALIZATION MEDICAL EXPENSES INCURRED 30 DAYS PRIOR TO HOSPITALIZATION  & POST HOSPITALIZATION MEDICAL EXPENSE INCURRED WITHIN 60 DAYS FROM DATE OF DISCHARGE FROM THE HOSPITAL”.
2. It is stated that the complainant assured by the OP that “ANY HOSPITAL DAY CARE CENTRE OR OTHER PROVIDER THAT IS NOT PART OF THE NETWORK”.  It is further stated that after that assurance the complainant purchased such policy & the OP also assured that you got Daily Cash Benefit for Rs.500/- per day upto maximum 20 days & also  Ambulance charge. It is further stated that the complainant’s husband was hospitalized at National Heart Institute, East of Kailash, Delhi from 01.04.2014 to 09.04.2014 for nine days, due to chest pain on 19.03.2014. Due to such problem the doctor admitted in hospital and diagnosis i.e its cardiac problem.
3. It is stated that the complainant approached to the OP2 telephonically for mediclaim at the time of hospitalization. It is stated that the complainant admitted in hospital as per assurance given by OP2 i.e medical claim passed within 15 days after submission of bills. It is further stated that the complainant operated in hospital and pays a sum of Rs.3,66,580.00 (Rs. 3,60,000.00 in hospital and Rs.6580.00 for pre examination). It is stated that complainant sent all documents to the company within 5 days after discharged from hospital.
4. It is stated that at the time of admission OP was informed as per rule and regulation of the policy. It is further stated that all the documents along with bills to the tune of Rs.3,66,580.00 to the OP for approving the same complainant was shocked and surprised when the claim repudiated saying that the NEFT payment of Rs.1,400,00.00 “Severe Diffused Triple Vessel Coronary Artery Disease, NYHA Class III, Normal LV function, NIDDM, Systemic Hypertension, Diabetic nephropathy & retinopathy. As per consultation paper Depart of Cardiology, VMCA & Safdarjung,  New Delhi, mentioned h/o T2DM since 1992. It is further stated that repudiation of the legitimate claim by the OP is malafide, arbitrary, wrong, illegal and totally unjustified. It is stated  that complainant was survive since 1992 with 100% cardiac problem. It is stated that after receiving letter that the complainant sent several email for pursuing his claim case.
5. It is stated that the complainant also sent a registered letter to IRDA on 13.04.2016, but there is no any proper response from IRDA also. It is further stated that thereafter the complainant approached several times to the OPs for mediclaim amount, but they keep on avoiding the matter on the one pretext or the other. It is stated that all the annexure which are annexed with the complaint are true copies of their originals. It is stated that the OP have failed to provide proper service and claim amount for which they were duty bound and did not give total expenses for which the complainant had taken the Hospitalization Benefit Policy for himself and his family. It is stated that the claim is legitimate and non payment/part payment of claim amount by the OP is resulting  monetary loss. Further OP had harassed and tortured mentally and physically to the complainant, and his family.
6. The complainant is seeking direction to OP to release the balance amount Rs. Of 2,26,580.00 with up to date interest ( for release the amount with interest @ 18% from the date of payment to till the realization of amount and compensation Rs.1,50,000/- on account of deficiency in service/unfair trade practice, physical pain, mental agony and harassment with litigation cost of Rs.5500/- in the interest of justice.
7. As per record OP1 served but failed to appear and also not filed WS. The OP1 proceeded ex parte vide order dated 16.05.2017.
8. OP2 filed detailed WS and taken preliminary objections that the present complaint as framed/pleaded and filed  before the hon’ble forum is not maintainable and same requires to be dismissed. It is stated that there is no deficiency in services on the part of OP2 and hence complaint filed by before this hon’ble consumer forum is not maintainable and is liable to be dismissed. It is stated that the contract of insurance is a contract of utmost good faith and the insured is required and expected to disclose the true facts and information without concealing any material facts. It is further stated that the complainant had failed to disclose the material facts rather concealed the same with the OP by not disclosing the facts that the insured was having some problem regarding Hypertension, (NHI – National Heart Institute) diagnosis Severe Diffused Tripple Vessel Coronary Artry Disease, NYHA Class III, Normal; IV Function, NIDDM, Systemic Hypertension, Diabetic nephropathy & rentinopathy. As per the consultation paper as submitted by the complainant of Department of Cardiology, VMCC & Safdarjung New Delhi mentioning h/o T2DM since 1992.
9. It is stated that the discharge summary of the National Heart Institute wherein the complainant husband had been admitted has mentioned Angina on exertion for last 2-3 months. It is further stated that currently the patient is NYHA Class III symptpmatic, Coronary Angiography revealed severe diffused triple vessel coronary artery disease with normal I.V. function, Coronary risk factors are NIDDM, system hypertension, obesity and history of cigarette.
10. It is stated that the contents of discharge summary and facts submitted that there in the cause of disease is due to NIDM and history of T2DM since 1992. And due to history of disease the claim comes under the clause of 4.2 of the policy as issued to the complainant. It is stated that the claim of the complainant is hit by the terms 4.2 of the policy which is terms as “Any disease other than those stated in the clause 4.3 and 4.4 of the policy contracted by the insured during the first 30 days from the commencement date of the policy.  The exclusion shall not however apply in case of the insured person have being covered under an insurance scheme with our company for a continued period of preceeding 12 months without any break.
11. It is stated that the OP had delivered complete set of policy covers to each and every insured at the time of acceptance of the premium and issue of the policy cover and same was provided to the complainant and in terms and conditions of the policy the insured was insured by the OP for a sum of Rs.2,00,000/- in the year 2009-2010 and the benefits in terms of the policy and the benefits were available to him.
12. It is stated that now as per the terms and conditions of the policy the complainant was entitled to the extend of 70% of  the total expenses of the sum insured as per the terms and conditions of the policy and according the complainant was paid the amount of Rs.1,4,000/- against the sum insured to the extend of Rs.2,00,000/-. It is further stated that considering the other policy  which was availed by the complainant is pertaining to Super Top Up Policy which is having inception date as 06.08.2010. The present claim was pertaining to the period 06.08.2013-05.08.2014. Policy was in the 4^th year. Due to history of disease it comes under the 4.1 Clause of the policy which stands issued to the complainant which is stated as “Any pre-existing condition as defined in the policy until 48 months of continued coverage of such insured person have elapsed, since inception of his or her Super Top Up Medicare Policy with the company. Pre Existing Condition definition – Any condition, ailment or injury or related condition for which insured person had signs of symptions, and/or were diagnosed, and/or received medical advice/treatment, within 48 months prior to his/her Super Top Medicare Policy with the company”. Therefore as per the above terms and conditions of the policy the claim of the complainant is not  covered under the Super Top Medicare Policy.  
13. It is stated that this hon’ble forum has no territorial jurisdiction to try and adjudicate the present complaint as the office of the OP2 the policy issuing office is situated at Vasant Vihar, Delhi, and complainant husband was admitted in the National Heart Institute, Eash of Kailash New Delhi and there is no cause of action has in the present jurisdiction of the hon’ble forum to try and adjudicate the present complaint, therefore the present complaint is liable to be dismissed. It is further stated that the complaint of the complainant is describing the various annexure from A to G but non of the documents are marked as Annexures over the same on any of the documents as filed along with the complaint and on account of defective pleading and enclosing the annexures along with the same in the complaint the complaint deserves to be dismissed on merits.
14. It is stated that this hon’ble forum has no power to assume functioning of  the Civil Court as the question involved in the present case is of a serious nature and requires full fledged investigation. The scope of enquiry before this Hon’ble Forum is very limited i.e, “deficiency in services”.
15. It is stated that complainant had taken the medi claim policy form the OP and the had issued Individual Health Insurance Policy 2010 bearing No. 041300/48/13/97/00001285 for the period of 06.08.2013 to 05.08.2014, being covered under the Individual Health Insurance Policy 2010 issued by the OP to which E Meditek Solutions Ltd a TPA Private Limited is a company is acting as an intermediary services provider for the settlement of all the claims and disputes regarding the claims and its adjudication on behalf  of the OP.
16. It is stated that the complainant had further taken the mediclaim policy under the Super Top Up Medicare Policy vide policy bearing no. 041300/48/13/36/00001284 for the period of 06.08.2013 to 05.08.2014. It is further stated that the complainant had claimed that wherein Shri L.N Aggarwal the husband of the complainant has been insured for Rs.2,00,000/- it had been a policy matter that notwithstanding enhancement for claims arising in respect of ailment, disease or injury contracted or suffered during a preceding policy period, liability of the company shall be only to the extend of the sum insured under the policy in force at the time of when it was contracted or suffered during the currency of such renewed policy or  any subsequent renewal thereof.
17. It is stated that the present complaint of the complainant is not maintainable because the complainant had suppressed the material facts and has not to come before the hon’ble court with clean hands and had suppressed the material facts of there treatment which were done earlier and had not submitted the same to the OP. The E-Meditek Solutions acting for an on behalf of the OP2 had deducted the amount of claim of the complainant and had given the detailed reply vide the documents has been filed along with the complaint by the complainant to the extend of settlement of there claim for a sum of Rs.1,40,000/- which stands admitted by complainant having received the same.
18. It is stated that the contract of the insurance and the insured is thus under a solemn obligation to make the full disclosure of material facts which may be relevant for the insurer to take into account while deciding whether  the proposal should be accepted or not while making a disclosure of the relevant facts it is the duty of the insured to state them correctly which cannot be diluted.  It is stated that the OP1 who is a person rendering the services to the general public at large has been impleaded as necessary party and residing in Shalimar Bagh, Delhi, and the while impleading his a necessary party the jurisdiction of the hon’ble forum has been pleaded, and the OP1 has no relevance with the current complainant there his name is required to be deleated from the array of complainant.
19. On merit all the allegations made in the complaint are denied by OP and reiterated contents of preliminary objections.
20. Complainant filed  rejoinder to the WS of OP2  and denied all the allegations made therein  and reiterated contents of complaint. It is stated that the husband of complainant has no history of severe diffused triple vessel coronary artery disease, NYHA Class III or any other disease as alleged by OP to prior  to 19.03.2014 and for the first time diagnosis only in March 2014 when the husband hospitalized for chest pain. It is further stated that history of type II diabetes Mellitus was disclosed to attending doctor at Safdarjung Hospital and OP1 sh. Deepak Sharma agent of OP2. It is stated that in the year 1997-98 the OP company itself provided to the insured no claim bonus. It is stated that in the year 1997-98 the history of diabetes mellitus was clearly disclosed by the complainant. It is stated that present claim is not covered under clause 4.1. It is stated that complainant is entitled to all the reliefs claimed in the complaint.
21. The complainant filed evidence by way of his affidavit. The complainant relied on documents copy of GPA Ex.CW1/1, copy of Insurance Policy Ex.CW1/2 (Colly), copy of terms and conditions of mediclaim Ex.CW1/3, copy of bills Ex.CW1/4 (colly), copy of claim Ex.CW1/5, copy of letter of OP dated 09.12.2015 Ex.CW1/6, copy of various Emails and letters Ex.CW1/7 (colly), copy of letter dated 13.04.2016 written to IRDA Ex.CW1/8 and copy of cardiac report Ex.CW1/9
22. OP filed evidence by way of affidavit of Angela Samag Deputy Manager and reiterated contents of WS.
23. Written statement filed  by complainant as well as OP.
24. We have heard Sh. Himanshu Singh counsel for complainant and Sh. Gurmeet Singh Ahuja counsel for OP2. OP1 is ex parte.
25. It is admitted case of parties  that complainant had taken the mediclaim  policy and individual health insurance policy 2010 bearing no.041300/48/13/97/00001285 for the period 06.08.2013 to 05.08.2014 being covered under the Individual Health Insurance Policy 2010. The E Meditek Solutions Ltd. TPA acts as an intermediary service provider for  the settlement of all the claims and disputes and adjudication, thereof on behalf of OP. It is further admitted case of parties that complainant had taken the mediclaim policy under the Super Top Up Medicare Policy bearing no.041300/48/13/36/00001284 for period 06.08.2013 to 05.08.2014.
26. It is admitted case that complainants husband was hospitalized at National Heart Institute, East of Kailash, Delhi from 01.04.2014 to 09.04.2014 due to chest pain on 19.03.2014 and doctors diagnosis it as cardiac problem. We have gone through the documents filed on record. The complainant has not filed on record the discharge summary, however, as per annexure F filed by complainant which is an email received from OP Insurance Company mentioned as under:-

Hospitalization detail as per discharge summary-DOA-01.04.2014 - DOD-09.04.2014.

Discharge summary mentioning (NHI National Heart Institute) diagnosis Severe Diffused Tripple Vessel Coronary Artery Disease, NYHA Class iii, Normal LV function, NIDDM, Systemic Hypertension, Diabetic nephropathy & retinopathy. As per consultation paper – Department of Cardiology, VMMC & Safdarjang, New Delhi, mentioning h/o T2DM since 1992.

As per Discharge summary (NHI) mentioning – angina on exertion for last 2-3 months. Currently he is NYHA class III symptomatic. Coronary Angiography revealed severe diffused triple vessel coronary artery disease with normal LV function. Coronary risk factors are NIDDM, systemic hypertension, obesity and history of cigarette smoking. Procedure – Coronary Artery Bypass Grafting*3 (Off Pump).

As  per the above facts of the discharge summary, cause of disease isdue to NIDDM & history of T2DM since 1992.

27. The complainant had taken United Individual Policy which started from 30.07.2001 and United Super Top Up Policy which started from 06.08.2010. The Super Top Up Policy is a fresh policy which is having insured sum of Rs.3,00,000/- and as per terms and conditions of the policy i.e 4.1 clause the complainant admitted for treatment on 01.04.2014 i.e within 48 months of the Super Top Up Policy. The OP has not filed any documentary proof that since 2010 complainant has taken any reimbursement for Coronary Heart Disease. The claim of the complainant falls under the individual policy and according to terms and conditions of the same complainant is entitled for 70% sum insured in the case of major surgery. The Individual  Insurance  Policy of the complainant is having sum insured of Rs.2,00,000/-, therefore, entitled for 70% reimbursement i.e Rs.1,40,000/-. The complainant is not entitled 70% as per Super Top Up Medicare Policy because clause 4.1 of the policy comes into play. We are of the considered view that the reimbursement of Rs.1,40,000/- by the OP company is justified and in accordance with terms and conditions of the insurance policy.
28. On the basis of above observation and discussion present complaint is dismissed. No order as to cost. File be consigned to record room.
29. Copy of the order be given to the parties free of cost as per order dated 04.04.2022 of Hon’ble State Commission after receiving an application from the parties in the registry. The orders be uploaded on www.confonet.nic.in.

Announced in open Commission on  19.04.2024.

SANJAY KUMAR                 NIPUR CHANDNA                       RAJESH

       PRESIDENT                             MEMBER                                MEMBER