DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-II
Udyog Sadan, C-22 & 23, Qutub Institutional Area
(Behind Qutub Hotel), New Delhi- 110016
Case No.114/2013
Manoj Kumar Sharma
S/o Late Sh. Chander Prakash Sharma
R/o 178/7-8, Street No.2, Padam Nagar
Kishan Ganj, Delhi
….Complainant
Versus
Medsave Healthcare(TPA) Ltd.
F-701A, Lado Sarai, Behind Golf Course
New Delhi-110030
Shree Jeewan Hospital
67/1, New Rohtak Road, New Delhi-110005
Medi Assist India T.P.A Pvt. Ltd.
B-20, Sector 2, Near Sector 15 Metro Station
Noida, Uttar Pradesh 201301
United India Insurance Co. Ltd.
24, Whites Road, Chennai-60014
….Opposite Parties
Date of Institution : 07.03.2013
Date of Order : 01.12.2022
Coram:
Ms. Monika A Srivastava, President
Ms. Kiran Kaushal, Member
Sh. U.K. Tyagi, Member
ORDER
Member: Sh. U.K. Tyagi
1. Complainant has requested to pass an order directing OPs i.e (i) Medisave Healthcare (TPA) Ltd, (ii) Shree Jeewan Hospital.(iii) Medi Assist India (TPA) Pvt. Ltd. (iv) United India Insurance Co. Ltd. (hereinafter referred to as OP-1 to OP-4 respectively).
- to pay the claim of Rs.23,075/- with interest @18% per annum till the disposal of the complaint.
- allow compensation of Rs.50,000/- in favour of the complainant;
- allow litigation cost of Rs.20,000/- in favour of the Complainant.
- pass any such further order which this court may deem fit in the interest of justice.
2. Brief facts of case are as under:-
The Complainant purchased an insurance Policy No. 040401/48/11/97/00001565 from OP-4 on 19.08.2009. The OP-1 issued a card and the same was valid for 03 years. Thereafter, the OP-4 renewed further the said policy. The OP-3 issued a card. The said policy was valid till 18.08.2012. At the inception of the policy, the OP-4 promised to provide cashless facility in the hospitals on panel. On 19.01.2012, the Complainant suffered difficulty in breathing. He also felt cough, constipation etc. The OP-2 gave medication OP-1 advised the complainant to get admitted in case he does not feel relief. On 21.01.2012 the Complainant felt discomfort. On examination, OP-2 admitted the Complainant. The OP-2 kept Complainant for two days & he was discharged on 23.01.2012. The OP-1, OP-3 & OP-4 did not pay the charges of OP-2. The cashless facility was denied by OP-3 & OP-4. The Complainant incurred the expenses of hospitalization to the tune of Rs.22,675/- + Rs. 400/- (towards medical inspection on 19.01.2012). The OPs were under obligation to pay the expenses. The OP-1, denied the same on the premise of invoking the Clause 4.6 & 4.8 of the Policy. It is also averred that no policy documents was ever sent to the Complainant. Only Cards were sent to him by TPAs. The said disease was not only on account of alcohol and smoking. The said disease can take place due to many factors contrary to the arguments of OPs. The said policy was taken in 2009 and since then, nothing has happened to the Complainant. The denial of the claim was based on malafide & arbitrary attitude of OPs.
3. OP-4 filed its reply interalia raising some preliminary objection for dismissal of the complaint outrightly on the technical grounds. The Health Insurance Policy is a contract like any other contract and subject to adherence to the terms & conditions. The said claim of the Complainant falls under Clause 4.6 of the said policy. On the recommendations of TPA- who is professional agency under the provisions of IRDA Regulations, 2001, has repudiated the claim of the Complainant. The TPA investigated the claim and investigation as prepared is annexed and marked as ‘B'. It is further maintained that the Complainant has concealed the fact that he is chronic alcoholic and chronic smoker. It is revealed from the hospital record and was found that he is accustomed to alcoholic & smoking since 7/8 years as per prescription slip.
Clause 4.6 of the policy provides as under:
4.6 Convalescence, general debility run-down condition or rest cure, obesity treatment and its complications including morbid obesity, Congenital external disease/defects or anomalies, treatment relating to all psychiatric and psychosomatic disorder, infertility, sterility, Venereal disease, intentional self injury and use of intoxication drugs/alcohol.
4. OP-1, OP-2 & OP-3 were proceeded exparte on different dates by this Hon’ble Forum.
5. Both the parties i.e Complainant and OP-4 have filed written submissions and evidence-in-affidavit. Written statement is on record so is rejoinder. Oral arguments were heard and concluded.
6. This Commission has looked into carefully the material placed before us. Due consideration was given to the arguments. It is noted that the Complainant vide its replication stated that OP failed to show any connection between smoking/alcohol and said disease. He further contended that the onus to prove is upon the insurance company & other OPs. The Complainant stated that he occasionally took these things. He denied the purview of Clause 4.6.
7. The OP-4 has relied upon the case of M/S Suraj Mal Ram Niwas Oil Mils… Vs United India Insurance Co. Ltd., whereby the Hon’ble Supreme Court held that “in construing the terms of a contract of insurance, the words used therein must be given paramount, and it is not open for the courts to add, delete or substitute any words”
8. But in the instant complaint, the moot point is whether the Complainant concealed some material facts from the knowledge of the OP. This Commission noted with alacrity that the Complainant had maintained in its complaint that the policy documents was not supplied to him. As per IRDA Regulation, the supply of policy documents is obligatory on the part of OP. It is further noted that the OP-4 has not specifically denied this contention of the Complainant and has not led any substantive evidence to disprove the contention of the complainant.
9. In view of above narrations and material placed on record, the Hon’ble Supreme Court in the case of Man Mohan Narula Vs. United India Insurance Co. Ltd. has held in recent decided case on 6th Dec. 2021 that “respondents were not right in stating that as per terms and conditions of the policy “all the complications arising out of pre-existing conditions is not payable”. One of the risk factors for the aforesaid cardiac episode is diabetes mellitusII” in the above quoted case. Respecting the above ratio of the decision of the Hon’ble Supreme Court and other material placed on records, the this Commission is of the considered opinion that the OP-4 is squarely deficient in service and negligent in not producing the issued/ signed copy of the policy. OP-4 is directed to pay the amount of Rs. 23,075/- for medical expenses and Rs.5,000/- as compensation towards mental harassment and legal expenses within 03 months from the receipts of this order failing which rate of interest shall be levied @9% p.a on the amount of Rs.23,075/- till its realization.
File be consigned to the record room and order be uploaded on the website.
