DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II
Udyog Sadan, C-22 & 23, Qutub Institutional Area
(Behind Qutub Hotel), New Delhi-110016.
Case No. 135/2011
Smt. Minal Sadh
W/o Late Sh. Suhel Sadh
R/o D-45, Lajpat Nagar-II,
New Delhi-110024 ….Complainant
Versus
1. M/s MEDI Assist India (Pvt.) Ltd.
H-252, Kailash Plaza, Sant Nagar,
New Delhi
2. M/s Reliance General Insurance Co. Ltd.
K-24 & 25, Pearl Plaza, Sector-18,
Noida, U.P. .…Opposite Parties
Date of Institution : 13.04.2011 Date of Order : 16.10.2018
Coram:
Sh. R.S. Bagri, President
Ms. Naina Bakshi, Member
O R D E R
The case of the complainant, in nutshell, is that the husband of the complainant was insured under policy No.282510366351 issued by the OP No.2 on 06.01.09 for a sum of Rs.5 lakh the policy was valid upto 05.01.10. As per the mediclaim policy the complainant, her husband and her son were duly insured by the OP No.2. At the time of the issuance of the said policy the OP No.2 had completed all formalities including the medical check-up of all the insured persons and OP No.2 issued the said policy. The husband of the complainant, namely, Sh. Suheel Sadh was hospitalized in Apollo Indraprastha Hospital, New Delhi on 09.04.09 due to pain in abdomen. The diagnose was done by the doctor as Acute Pancreastitis. After admission in the hospital the complainant had lodged a claim before the OP No.1 and OP No.2 and paid initial amount of Rs.60,000/- to the complainant. On 26.04.09 the husband of the complainant was expired in the hospital due to severe Acute Pancreastitis with acute renal failure with ARDS Sepsis with severe sepsis with septic shock and the complainant had to spend approx. Rs.15 lakhs. The complainant lodged the claim before the OPs on 14.05.09. The OP No.2 repudiated the claim due to pre-existing clause. Even the consulting doctors had repeatedly advised the complainant and the OPs in writing that this particular element cannot be preexisted as it was a sudden illness. It is submitted that the complainant requested several times to the OPs to release the fund as per the entitlement of the mediclaim from the OPs i.e. Rs.5 lacs. When no reply was received the complainant sent a legal notice dated 29.06.10 which was duly served by the OPs but inspite of service of legal notice no reply was received from the OP. Hence, pleading deficiency in service on the part of the OPs the complainant has filed the present complaint for issuing following directions to the OPs
i. to direct the OP to a sum of Rs.5 lacs as sum insured amount.
ii. to direct the OP to pay Rs.1 lakh as damages for causing mental
pain and agony.
iii. to direct the OP to pay Rs.25000/- as litigation expenses to the
complainant.
OP No.1 was proceeded exparte vide order dated 18.04.12.
OP No.2’s defence was struck off on 12.09.2012.
Complainant has filed his own affidavit in evidence as well as written arguments.
We have heard the arguments on behalf of the complainant and have also carefully gone through the file.
The complainant has filed the copy of policy issued by the OP which we mark as Annexure-A for the purpose of identification. It is mentioned in the policy that the sum assured towards hospitalization expenses is Rs.5 lakhs. We mark the copy of the repudiation letter as Annexure-2. The copy of the bill issued by Apollo Indraprastha Hospital, New Delhi as Annexure-3. The complainant has sent a legal notice dated 29.06.10 to the OPs but no reply was received which we mark as Annexure-4. Dr. Nalin Nag working in Apollo Indraprastha Hospital, New Delhi vide letter dated nil stated that as follows:-
“ Regarding disallowing cashless facility to patient Mr. Suhel Sadh aged 33 years admitted as a case of Acute Fulminate pancreatitis with multi organ failure and shock in gastro ICU.
This is to state that there is no history of preexisting disease. No history of “Alcohol Abuse”. Patient had pain abdomen on 8.4.09. Ultrasound was done on 9th morning for the first time which showed biliany calculi and fluid in abdomen. He was hospitalized of 9th at Indraprastha Apollo Hospital with rapidly deteriorating condition of a acute abdomen which subsequently diagnosed as Acute Pancreatitis. There is no evidence of any preexisting disease or any condition related to the disease.”
Averments made in the complaint and evidence led by the complainant have remained uncontroverted and unchallenged. Hence, there is no reason to disbelieve the version of the complainant.
It is clear from the record the OP No.2 had issued the policy to the complainant for hospitalization expenses as Rs.5 lakh. The treating doctor at Apollo Hospital stated that the patient was not suffering from pre-disease, no history of “Alcohol Abuse”. Patient had pain abdomen on 08.04.09. There is no evidence of any pre-disease or any condition related to the disease.
Even after expert report from the doctor the OPs failed to make the payment as per the terms and conditions which amounts to deficiency in service or unfair trade practice on the part of OP No.2.
In view of the above discussion, we hold that the OP Company committed deficiency in service while rejecting the claim in question of the complainant. We, therefore, allow the complaint and direct the OP-2 Company to pay Rs.5 lakhs along with interest @ 6% p.a. from the date of filing of the complaint till realization towards the claim in question and Rs.50,000/- in lumpsum towards compensation for mental agony and harassment and cost of litigation to the complainant within one month from the date of receipt of copy of this order failing which the OP Company shall become liable to pay the above stated amount of Rs.5 lakhs along with interest @ 9% p.a. from the date of filing of the complaint till 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.
Announced on 16.10.18.
