CONSUMER DISPUTES REDRESSAL FORUM – X
GOVERNMENT OF N.C.T. OF DELHI
Udyog Sadan, C – 22 & 23, Institutional Area
(Behind Qutub Hotel)
New Delhi – 110 016
Case No.755/2008
SH. NAVEEN THAKUR
C/O TODAY HOMES & INFRASTRUCTURE PVT. LTD.,
B-1503, STATESMAN HOUSE,
BARAKHAMBA ROAD, NEW DELHI-110001
…………. COMPLAINANT
Vs.
- M/S IFFCO-TOKIO
GERNAL INSURANCE COMPANY LTD.,
THROUGH ITS MANAGING DIRECTOR/DIRECTOR
HAVING ITS REGISTERED OFFICE AT:-
34, NEHRU PLACE, NEW DELHI-110019
- M/S PARAMOUNT HEALTHCARE PVT. LTD.,
F-90/12, NEAR ESI HOSPITAL,
OKHLA INDUSTRIAL AREA, PHASE-I,
NEW DELHI-110020
…………..RESPONDENTS
Date of Order: 07.10.2016
O R D E R
Ritu Garodia – Member
The complaint pertains to repudiation of mediclaim by OP-1. The complainant purchased a medical policy bearing Patient ID No.11189015 for a period from 18.04.07 to 17.04.08. The complainant was admitted at Max Devki Devi Heart & Vascular Institute for removal of lesion. Medical prescription and discharge summary is annexed with the complaint. The complainant had earlier undergone a CT Scan which showed vascular malformation in the subcutaneous region. The complainant filed a cashless claim for the surgery. Additional information was sought by OP and the complainant forwarded the details alongwith copy of an estimate for the cost of surgery and hospitalization expenses of Rs.95,000/-. OP vide letter dated 13.03.08 enquired whether the disease was congenital in nature. The letter dated 14.3.08 was issued by the Director of Vascular Surgery at Max Devki Devi Heart & Vascular Institute stating that the term congenital cannot be used for vascular malformations as they may manifest late in life. A copy of the letter is annexed with the complaint. However, OP refused the said claim. Surgery was not performed, as the complainant did not get the required finances from insurance company. Complainant underwent conservative management of disease in the absence of surgery. The complainant thereafter sent legal notice dated 09.3.08 to OP for refund of amount of Rs.22,000/- spent by him on consulting specialist and medication for the disease. Copies of various bills annexed. Complainant prays for refund of Rs.37,650/- as the expenses incurred on disease alongwith compensation.
OP in its reply and affidavit has stated that complainant is not a consumer as the Group Insurance Policy was purchased by the company. OP has also stated that the print out for the definition of Vascular M\malformation from the internet describes it to be congenital. No such print out has been annexed. It states that vascular malformation occur during foetal development and it exists at the time of birth and is termed as congenital ailment. OP has also stated that the complainant being interested in various sports has increased the chances of vascular malformation and as such the disease was pre-existing. Further expenses cannot be reimbursed as the disease itself is not covered being congenital in nature.
Perusal of the file reveals that the insurance cover is admitted by both the parties. It is a settled law that issue of insurance relates to service and no profit is being generated by taking insurance cover and as such falls within the purview of consumer dispute. The only issue before us is whether vascular malformation is congenital in nature and can it be termed as pre-existing. The report of Director, Vascular Surgery at Max Devki Devi Heart & Vascular Institute is reproduced as under:-
- The patient is suffering form ‘VASCULAR MALFORMATION’ in the right inguinal region. This is painful due to thrombosis, and thus surgical excision is warranted.
- Currently, the International Society for Vascular Anomalies (1996) classifies vascular malformations as ‘vascular anomalies’. The term ‘congenital’ has been dropped, because these lesions may manifest late in life (Reference: Rutherford RB (ed) textbook of Vascular Surgery (Sixth Edition, 2005), Volume 2, page 1598).
- The etiology of ‘vascular malformations’ is not clearly understood, even by the leading world authorities.
- In view of the fact that the patient has first presented with the lesion at the age of 38 years, it is difficult to opine whether the lesion is congenital or not. Typically, ‘congenital lesions’ present at birth or in early childhood, at not in 4th decade of life.
OP has not filed any document in support of its contention that the said disease was congenital in nature. The reply filed by OP is vague and full of conjecture that the complainant being interested in various sports has increased the chances for the development of vascular malformation.
No evidence has been filed by OP that the said disease was within the knowledge of complainant or any treatment has been taken form any hospital for the said disease before taking the policy. A common man purchases a medical policy to secure himself against whims and vagaries of ill health. Nonetheless when the malady strikes, he is thrown at the mercy of these mercenary insurance company and subjected to rejection at the arbitrary whim of insurance company inspite of paying health coverage premium for years altogether.
In the instance case, the complainant has no option but to opt for conservative management by taking medicines, injection and consultation as his cashless claim was denied on flimsy presumption of being congenital in nature. OP in the high handed manner refused to give any credibility to senior consultant, specializing in the field of vascular malformations.
We have no reason to disbelieve the expert opinion on this particular disease as provided by the Director, Vascular Surgery at Max Devki Devi Heart & Vascular Institute. Complainant annexed bills for Rs.13800/-, Rs.500/-, Rs.320/-, Rs.30/-, Rs.716/-, Rs.1500/-, Rs.1000/-, Rs.320/-, Rs.700/- for the treatment of the aforementioned disease.
We, therefore, hold OP guilty of deficiency in service and direct it to refund Rs.18,886/- alongwith 9% interest from the date of claim till payment. We also award Rs.10,000/- as compensation towards mental trauma, physical inconvenience and harassment and Rs.5,000/- towards litigation expenses.
Let the order be complied within one month of the receipt thereof. The complaint stands disposed of accordingly.
Copy of order be sent to the parties, free of cost, and thereafter file be consigned to record room.
(D.R. TAMTA) (RITU GARODIA) (A.S. YADAV)
MEMBER MEMBER PRESIDENT
