District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No. 182/2020.
Date of Institution:03.07.2020.
Date of Order: 17.07.2023.
Naresh Kumar son of Shri Hardwari Lal, resident of House No. 135, Rajiv Nagar, Shiv Mandir, Sector-18, Faridabad, Aadhar card No. 734713890705.
…….Complainant……..
Versus
M/s. Cholamandalam MS General Insurance Company Limited, Plot NO. 39, IInd floor, Samyak Tower, Opp. Metro Pillar No. 120, Pusa Road, Karol Bagh, New Delhi – 110 005 through its Divisional Manager/principal officer (Service be effected through its Divisional Officer at Faridabad).
…Opposite party
BEFORE: Amit Arora……………..President
Mukesh Sharma…………Member.
Indira Bhadana………….Member.
PRESENT: Kr.Satish Chauhan, counsel for the complainant.
Sh. Rakesh Dabaas, counsel for opposite party.
ORDER:
The facts in brief of the complaint are that the complainant obtained an insurance policy from the opposite party which includes the insurance of his wife Mrs. Kanta Sharma also duly issued by the opposite party bearing Insurance policy No. 2856/00217537/000/02 valid from 04.10.2019 to 03.10.2020 for a sum of Rs.2,00,000/- (Rs.1,00,000/- for each member). The wife of the complainant name client namely Smt.Kanta Sharma became seriously ill and she remained hospitalized at QRG Medicare Limited, Plot No.1, Sector-16, Faridabad – 121002, as she was suffering from recurrent epistaxis bilatres nose since 3 days and there was severe bleeding, as such there was case of DCMP, EF-25-30% opn 10.12.2019. Hence on the basis of above said mediclaim policy, the complainant got admitted his wife in the above said hospital, on 10.12.2019, where she got admitted as an indoor patient and remained there upto 12.12.2019. The complainant informed the opposite party about the ailment of his wife immediately on 10.12.2019 and during that period the complainant spent Rs.61,539/- on account of doctors fees etc. According the complainant submitted his claim form to the opposite party for the above said amount. Inspite of completing each and every formality by the complainant, the opposite party did not pay even a single penny to the complainant and they issued cashless denial letter to the hospital on 09.12.2019. The complainant sent legal notice dated 19.3.2020 to the opposite party through registered post but all in vain. The aforesaid act of opposite party amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite party to:
a) pay to the complainant Rs.61,539/- i.e the amount already spent by the complainant on account of treatment of wife of complainant alongwith interest @ 18% p.a. from the date of its due till realization of whole amount, immediately, on the basis of insurance policy bearing No. 2856/00217537/02 valid form 4.10.2019 to 3.10.2020.
b) pay Rs. 22,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 22,000 /-as litigation expenses.
2. Opposite party put in appearance through counsel and filed written statement wherein Opposite party refuted claim of the complainant and submitted that at the very threshold of the allegations contained in the complaint, since , as per record of treating hospital the complainant’s wife was diagnosis & treated for “Recurrent epistaxis bilateral nose K/C/O (known case of) DCMP” from 10.12.20219 to 12.12.2019 and further in view of the other relied upon documents, it was observed that the sign & symptoms of the pre-existing disease DCMP existing since 4 years, which was prior to the inception of policy i.e.04.10.2017, thus, present ailment (epistaxis) was considered as complications of pre existing disease and the claim of the complainant stands inadmissible & non non payable in view of exclusion clause C-3 (No indemnity was available or payable for claims directly &Indirectly caused by, arising out of connected to any pre-existing condition(s) as defined in the policy until 48 consecutive months of the continuous coverage have elapsed, since inception of the first policy with us”) of the insurance policy so issued in this regard. The complainant had neither any cause of action nor locus standi to file the present complaint. The complainant had lodged reimbursement mediclaim vide under claim form dated 01.01.2020 by endorsing entire treatment papers by alleging indoor treatment w.e.f. 10.12.2019 to 12.12.2019 therein with QRG Health City Hospital, Faridabad as to his wife Kanta Sharma, so received by the opposite party on even date. During processing of the claim at the end of the opposite party, it was revealed that since as per record of treating it was observed that the sign & symptoms hospital the complainant’s wife was diagnosis & treated for “Recurrent expistaxis bilateral nose K/C/O DCMP from 10.12.2019 to 12.12.2019 and further in view of the other relied upon documents. It was observed that the sign & symptoms of the pre-existing disease DCMP existing since 4 years, which was prior to the inception of policy i.e. 04.10./201, thus, the present ailment (epistaaxis) was considered as a complications of pre existing disease and he claim of the complainant stand inadmissible & non payable in view of exclusion clause C-3 (No indemnity was available or payable for claims directly & directly caused by, arising out of or connected to any pre existing conditions as defined in the policy until 48 consecutive months of continuous coverage had elapsed, since inception of the first policy with us”) of the insurance policy so issued in this regard. As such, opposite party had treated the subject claim as “Repudiated” by closing the file in terms of “letter of intimation” dated 14.01.2020, which decision cannot be termed unconscionable at all. Opposite party denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. The parties led evidence in support of their respective versions.
4. We have heard learned counsel for the parties and have gone through the record on the file.
5. In this case the complaint was filed by the complainant against opposite party–Cholamandalam MS General Insurance Co. Ltd. with the prayer to: a) pay to the complainant Rs.61,539/- i.e the amount already spent by the complainant on account of treatment of wife of complainant alongwith interest @ 18% p.a. from the date of its due till realization of whole amount, immediately, on the basis of insurance policy bearing No. 2856/00217537/02 valid form 4.10.2019 to 3.10.2020. b) pay Rs. 22,000/- as compensation for causing mental agony and harassment .c) pay Rs. 22,000 /-as litigation expenses.
To establish his case the complainant has led in his evidence, affidavit of Naresh Kumar, Annexure C-1 – insurance policy, Annexure C-2 – Cashless denial letter to the hospital dated 6.12.2019, Annexure C-3 – discharge summary, Annexure C-4 – Final bill of supply summary, Annexure C-5 & 6 – Invoice cum receipt, Annexure C-7 – legal notice, Annexure C-8 – postal receipt.
On the other hand, counsel for the opposite party strongly agitated and opposed. As per the evidence of the opposite party Ex.RW1/A – affidavit of Shri Surjeet Kumar Sahu dy. Manager (Legal), M/s. Chola Mandlam MS General Insurance Company Limited, Pot No. 39, Samyak Tower 2nd floor, Metro Pillar NO. 120, Pusa Road, New Delhi , Annexure A - insurance policy, Annexure –B – Claim form , Annexure C – OPD card,, Annexure D – discharge summary, Annexure E – Final Bill of supply, Annexure F - Transthoracic Echo report, Annexure G - OPD card, Annexure H – OPD card, Annexure I – OPD card, Annexure J - -Health Claim Repudiation letter dated 14.01.2020.
6. As per the evidence led by the complainant as well as the opposite party, there is no treatment of heart surgery. Treatment of the synis is there which is not the part of the exclusion clause. After going through the evidence led by the parties, the Commission is of the opinion that the complaint is allowed. Opposite party 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 alongwith interest @ 6% p.a. from the date of filing of complaint till its realization. Opposite party is also directed to pay Rs.2200/- as compensation for causing mental agony & harassment alognwith Rs.2200/- as litigation expenses to the complainant. Compliance of this order be made within 30 days from the date of receipt of copy of this order. File be consigned to the record room.
Announced on: 17.07.2023 (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.
