District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.170/2020.
Date of Institution: 22.6.2020.
Date of Order: 14.11.2022.
Sh. Ricky Kathuria S/o Sh. Bharat Bhushan Kathuria R/o 703, Everest Omaxe Heights, Sector-86, Faridabad, Presently R/o E-1403, Florida Apartment, Sector-82, Faridabad – 121002.
…….Complainant……..
Versus
1. M/s. Aegon Life Insurance Company Limited, Regd. Office:- Building No.3, 3rd floor, Unit NO.1, Nesco IT Park, Western Express Highway, Goregoan (East) Mumbai - 400 063 through its Managing Director & Chief Executing Officer Shri Vineet Arora.
Service to be effected at:-
Second floor, SCO-30, HUDA Market Road, Sector-15, Part-11, Gurugram, Haryana – 122001.
…Opposite party……
2. M/s. Asian Institute of Medical Sciences, Corporate Office:- Badkhal Flyover Road, Sector-21A, Faridabad through its Managing Director/Sr. Consultant and Interventional Cardiologist Dr. Umesh Kohli (Treating Doctor).
….Performa opposite party……
Complaint under section-12 of Consumer Protection Act, 1986
Now amended Section 34 of Consumer protection Act 2019.
BEFORE: Amit Arora……………..President
Mukesh Sharma…………Member.
Indira Bhadana………….Member.
PRESENT: Sh. Ashok Muthreja, counsel for the complainant.
Opposite party No.1 ex-parte vide order dated 16.03.2021.
Sh. J.S.Bhadana, counsel for opposite party NO.2.
ORDER:
The facts in brief of the complaint are that the complainant was insured with opposite party No.1 company vide policy No. 518042287882 on 29.04.2018 under the scheme “Aegon Life Term Plus Insurance Plan (138N060V02)”, valid from 29.04.2018 to 28.04.2015. The said policy covers the following benefits:-
a) Sum assured will be paid in a lumpsum either on the death of the policy holder or on diagnosis of terminal illness, whichever happens first.
b) Future premiums will be waives off in a lumpsum assured will be paid to the policy holder on diagnosis of any of the covered 36 critical illnesses. On 14.08.2018 the complainant experienced as a chest pain and swatting and thus was rushed to the Asian Institute of Medical Sciences, Near Badkhal Flyover, Sector-21A, Faridabad, where he was treated and diagnosed by the performa opposite party Dr. Umesh Kohli, and the complainant remained admitted in the hospital till 17.08.2018 and was discharged in the evening hours of 17.08.2018. It was pertinent to mention that earlier on 18.09.2017 the complainant had visited the
perform opposite party No.2 hospital as outdoor patient and after consultation with the doctor concerned, he was advised some medicines, but the opposite party No.1 had wrongly observed that the complainant was suffering from nervous decease since on 18.9.2017 i.e. the date of the routine check-up with the perform opposite party No.2 as outdoor patient. During the course of the treatment in the hospital his ECG was done by the treating doctor, which showed acute interior wall MI & Screening Eco Study revealed mid anterior septum and Apex Hypokinetic, LVEF-45%. The complainant had also underwent coronary Angiography on 14.08.2018 which revealed that double vessel decease for which primary PTCA with stanting of mid LAD was done in same sitting with 3.5 x 38M.M. Xience Xpedition. T IMI-3 flow achieved. It was pertinent to mention that the doctor i.e. the performa opposite party had categorically mentioned in the discharge summary that “patient was admitted with complaints of chest pain on and of associated with swatting since morning on the day of admission. There was no history of palpitation, syncope, Fever & cough, No past history of DM, CAD or COPD. Now patient admitted for further evaluation & management”. As per the admitted case of the opposite parties, the complainant felt with critical illness comes under 36 critical illnesses under the policy. After getting discharge from the hospital, the complainant approached the opposite party for payment of the claim amount i.e. lumpsum amount of Rs.10,00,000/- as per the policy, but the opposite party company illegally, arbitrarily had declined the claim of the complainant vide their letter dated 13.12.2018 with the observation that “the claim is not admissible and the WOP on critical illness & critical illness rider had terminated, on account of having suppresses/withheld correct information regarding their health at the time of affecting the insurance with us”. The opposite party further mentioned that the complainant was suffering from nervous disorder and stated that in Section 5 of the
proposal from the complainant had specifically mentioned as “Yes” against column 1 of Section 5 of medical history i.e. blood pressure/cholesterol/heart decease and in column No. 7 the complainant in front of nervous or psychiatric disorder mentioned as “NO” as the complainant had never suffered with nervous disorder and he was only suffering from high blood pressure, but the opposite party had illegally and arbitrarily on the basis of OPD card of the complainant dated 18.09.2017 wherein an alprox 0.25 Mg was prescribes as SOS and there was no mentioned about any nervous disorder, but the opposite party had taken it otherwise as per their own choice and repudiated the claim of the complainant illegally and arbitrarily. Against the said letter dated 13.12.2018 regarding repudiation of the claim by the opposite party, the complainant preferred an appeal before the office of the Insurance Ombudsman FCO-101-103, Batra Building Second Floor, Sector-17D, Chandigarh and was reference was registered as CHD-H-001-1920-0215, where the complainant and the representatives of the opposite party personally appeared before the Chairman Insurance Ombudsman who had also repeated the version of the opposite party and dismiss the claim of the complainant on merits. The aforesaid act of opposite parties amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite parties to:
a) pay Rs.10,00,000/- alongwith interest @ 24% p.a. as per the policy.
b) pay a sum of Rs.15,030/- on account of medical expenses incurred by the complainant himself.
c) pay Rs. 50,000/- as compensation against physical torture.
d) pay Rs. 22,000 /-as litigation expenses.
e) pay Rs. 2,00,000/- as compensation for causing mental agony and harassment .
f) pay a sum of Rs.90,000/- as loss of income, as the complainant could not do his official duties during the treatment.
2. Registered notice was sent to opposite party No.1 on 15.02.2021 not received back either served or unserved. Tracking details filed in which item Delivery Confirmed. Case called several times since morning but none had appeared on behalf of opposite party No.1. It was already 3.35p.m. More than one month had been expired. Therefore, opposite party No.1 was hereby proceeded against exparte vide order dated 16.3.2021
3. Opposite party No.2 put in appearance through counsel and filed written statement wherein Opposite party No.2 refuted claim of the complainant and submitted that as per the discharge summary the complainant approached the answering opposite party on 14.08.2018 with certain complaints. After approaching the opposite party hospital the concerned doctor examined the complainant and thereafter, he was diagnosed chest pain and swatting and thus he was admitted in Asian Institute of Medical Sciences on 14.08.20218 and the complainant remained admitted there till 17.08.2018. He was discharged on 17.08.2018 and advised treatment as per the discharge summary. The complainant was required procedures for the treatment and as per the required treatment the procedure was conducted and the complainant was discharged satisfactorily in a stable condition. It was respectfully submitted that during the treatment the answering opposite party sent the entire papers of the treatment as well as other concerned documents to the insurance company i.e opposite party No.1 but the insurance company had rejected the case of the complainant. Opposite party No. 2 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
4. The parties led evidence in support of their respective versions.
5. We have heard learned counsel for the parties and have gone through the record on the file.
6. In this case the complaint was filed by the complainant against opposite parties– Aegon Life Insurance Company Limited & Ors. with the prayer to: a) pay Rs.10,00,000/- alongwith interest @ 24% p.a. as per the policy. b) pay a sum of Rs.15,030/- on account of medical expenses incurred by the complainant himself. c) pay Rs. 50,000/- as compensation against physical torture. d) pay Rs. 22,000 /-as litigation expenses. e) pay Rs. 2,00,000/- as compensation for causing mental agony and harassment . f) pay a sum of Rs.90,000/- as loss of income, as the complainant could not do his official duties during the treatment.
To establish his case the complainant has led in his evidence, Ex.CW1/A – affidavit of Shri Ricky Kathuria Ex.C-1 – insurance policy, Ex.C2(colly) – Out Patient Department Card, Ex.C-3(colly) – Discharge summary, Ex.C-4 - letter dated 13.12.2018 – not readable, Ex.C-5 – letter dated 04.02.2020.
On the other hand counsel for the opposite party No.2 strongly
agitated and opposed. As per the evidence of the opposite party No.2, affidavit of Shubham Mittal S/o Shri Vijay Mittal aged about 27 years working as a Company Secretary at Asian Institute of Medical Sciences, Badkhal Flyover Road, Sector-21A, Faridabad,, Ex.R-1(colly) – Face sheet.
7. In this complaint, on 14.08.2018 the complainant experienced a chest pain and swatting and thus he was rushed to Asian Institute of Medical Sciences (Proforma opposite party) where he was treated and diagnosed as a case of
“Coronary Artery Disease, Acuyte Interior Value MI, Hypertension and Double vessel diseases: and accordingly the treating doctors of performa defendant done Coronary Angiography on 14.08.2018 as well as primary PTCA with stunting of Mid LAD (3.5 x 38mm Xience Xpedition LL), and after that the complainant was discharged from the hospital on 17.08.2018 with advise of follow up treatment.After getting discharged from the hospital the complainant approached the opposite party for payment of claim amount i.e lump sum amount of Rs.10,00,00/- as per the schedule of the policy which is mentioned in Cloumn 2 f the head “Plan details” of the policy as Ex.C-1 which is read as under:-
Part C of Policy
Benefits
First Heart Attack of specific Severity (Myocardial Infarction) is covered under the critical illness.
Definition of Critical illness ( mentioned in para C.2.1 of Part C of Policy)
“enhanced Critical illness Benefits (Lump sum i.e. sum of Rs.10,00,000/-“.
First Heat Attack of Specified Serverity (Myocardial Infraction)
1. The first occurrence of heart attck or myocardial infraction, which means the death of a portion of the heart muscle as a result of inadequate blood supply to the relevant area. The diagnosis for Myocardial Infarction should be evidenced by all of the following criteria.
. A history of typical clinical symptoms consistent with the diagnosis of acute myocardial infarction (For e.g. typical chest pain)
Opposite party repudiated the claim of the complainant vide letter Ex.C-4 wherein the opposite party gave the reason of repudiation of the claim that the complainant
had suppressed the correct information referred in Section 5 of the policy in column “Medical History.”
“Whereas in the coloun Section 5 the complainant had specifically mentioned that there is no history of respiratory disorder, chest and lung so as well as no history of nerves system etc, but the opposite party as well as the Ombudsman have wrongly rejected the claim and wrongly mentioned that the complainant had opted (Yes) to the nerves or cycrarcstic disorder. The complainant has opted (NO) in the column 5 & 7 of Section5 i.e. “Medical History” which clearly shows that neither the opposite party nor the Ombudsman have applied their mind and not properly gone through the documents and have illegal and arbitrarily repudiated the claim of the complainant.
Performa opposite party has admitted para Nos.4,5,7 and 10 of the complainant in its written statement qua the treatment and has specifically mentioned in para No.3 of their affidavit and para No.4 of the written statement that the doctor has done the treatment as per the required procedures according to medical terminology and also annexed the detailed treatment summary vide Ex.R-1 and mentioned that the complainant was admitted to the hospital with complaint of Chest Pain and swatting since morning and there is no history of palpitation SIMCO Fever and cough and also mentioned in the discharge summary that there is no history of DM, CAD or COPD which clearly shows that the conditions of the complainant at the time of admission was critical and it was his first hearty attack
and as such the complainant is entitled for benefit under the Term of the policy i.e lump sum amount of Rs.10,00,000/-as detailed above. It is evident from Ex.C-5 – the Ombudsman has given liberty to the complainant to move a fresh application at any other Forum/Court.
8. After going through the evidence led by the parties and the above submissions made by the complainant, the Commission is of the opinion that the deficiency on the part of the opposite party has been proved. Hence, complaint is allowed.
9. Opposite part No.1 is directed to process the claim of the complainant within 30 days from the date of receipt of the copy of order and pay the due amount to the complainant along with interest @ 6% p.a. from the date of filing of complaint till its realization. The opposite parttNo.1 is also directed to pay Rs.5500/- as compensation on account of mental tension, agony and harassment alongwith Rs.3300/- as litigation expenses to the complainant. Copy of this order be given to the parties concerned free of costs and file be consigned to record room.
Announced on: 014.11.2022 (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
(Indira Bhadana)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
