Haryana

Ambala

CC/202/2013

M/S S.S ASSOCIATE - Complainant(s)

Versus

M/S MODERN AUTOMOBILE - Opp.Party(s)

V.K. Aggarwal

14 Jul 2017

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AMBALA

 

                                                          Complaint case no.        : 244 of 2013

                                                          Date of Institution         : 24.09.2013

                                                          Date of decision   :          14.07.2017

 

1. Ajay Kumar Aggarwal S/o Sh. Ishwar Chander Aggarwal.
2. Archana Gupta W/o Sh. Ajay Aggarwal,

R/o house No.5531, Pansari Bazaar, Ambaal Cantt.

 

……. Complainant.

 

1. LIC of India, Ambala City through its Manager.   
2. LIC of India, Northern Zonal Office, Jeevan Bharti, 124, Cannaught Palace,      New Delhi through its Zonal Manager.
3. LIC of India, Div, office, Model Town, Karnal through its Sr. Divisional Manager.   
4. E-Meditek (TPA Services Limited), Corporate Office-Plot No.577, Udyog         Vihar, Phase-V, Gurgaon, Haryana-122016 through its Manager.

 

 ….…. Respondents.

 

 

BEFORE:   SH. D.N. ARORA, PRESIDENT

                   SH. PUSHPENDER KUMAR, MEMBER                   

                   MS. ANAMIKA GUPTA, MEMBER       

 

Present:       Sh. Ashutosh Aggarwal, counsel for complainant.

                   Sh. Dev Batra, counsel for OPs No.1 to 3.

                   OP No.4 already exparte.

 

ORDER:

                   In nutshell, brief facts of the present complaint is that the complainant had obtained a Health Plus policy bearing policy No.176106742 on 26.08.2008 from OP No.1 having sum assured of Principal Insured of the amount of Rs.2,00,000/- and sum of Insured Spouse of the amount of Rs.1,00,000 and the said policy is still enforce being renewed every year. Further submitted that the complainant No.2 suffered from some illness which was diagnosed as “multiple Uterine Fibroid” by Dr. Pardeep Muley_A consultant with Fortis Flight Lt. Rajan Dhall Hospital, Sector-B, Pocket-1, Aruna Asif Ali Marg, Vasantkunj, New Delhi-110070 and the procedure of surgery was done on 30.06.2011 at the above said hospital and the claim form duly completed alongwith hospital treatment, original bills and receipts were duly submitted with the OP No.1 on 11.07.2011. Further submitted that it was cash less policy but the OP declined to give the above said facility to the complainant and the complainant has to pay the treatment amount from his own pocket. Further submitted that the complainant filed all the papers to the OP No.1 to 3 for claim, an illegal and non-sustainable ‘letter of repudiation dt. 06.08.2011’ was issued by the OP No.3 wherein grounds for repudiating the genuine and bona-fide claim are as under:-

1. Surgeries not listed in the allowed surgeries.
2. Total hospitalization period less than 52 hours.
3. Surgeries not listed in the allowed surgeries.

                   The complainant was further advised- “In case you are not satisfied with our above decision of rejection, you may make an appeal for are look at your claim within one month at the following address:-The Manager (Health Insurance), LIC of India, Divisional Office”. Whereas in the present case, TPA i.e. E-meditech Services ltd. has issued “letter of Repudiation dt. 06.08.2011 illegally for which the said TPA was not competent to issue such letter. The complainant also appealed before the OP No.3 even the development health unit of OP No.3 vide its letter no. LIC/HI dt. 23.08.2011 has also confirmed the decision of the TPA of repudiating the claim in question without applying its own mind over the matter and the complainant vide letter dt. 08.09.2011 was constrained to approach the OP No.3 through registered post on dt. 10.09.2011 for the reconsideration of the impugned decision, which is totally based on false, frivolous and untenable ground. Further submitted that the complainant received a letter dt. 02.11.2011 from the OP No.2 wherein it was stated that “with reference to your letter dt. 20.10.2011, we may inform you that we have sent your case file for representation to R.M.(HI) New Delhi for further necessary action. On receipt of reply we will inform you accordingly. But to the utter surprise, the OP did not bother to reply the representation dt. 08.09.2011 and dt. 20.10.2011 of the complainant which clearly amounts to grave deficiency in service and indulgence in unfair trade practice. Further submitted that the complainant sent legal notice dated 11.02.2013 to the OP No.2 and 3 which was duly received by the OPs and postal acknowledgements signed by the OPs No.2 and 3 were received back. The OP No.2 sent reply dated 01.03.2012 to the Legal Notice wherein the claim of the complainant was illegal rejected on frivolous grounds that:-

                   “The claim for policy No.176106742 was not paid as the surgery “Multiple Uterine Fibroid” is not covered under the Surgeries for which the claim was lodged. Smt. Archana Gupta suffered from some ailment and was hospitalized from 30.06.2011 to 01.07.2011 i.e. less than 52 hours”.

                   Further submitted that the complainant No.2 was administered with Anesthesia as is done in the cases of other surgeries. The amount charged by the complainant against ‘packages/surgery/procedure’ was of the amount of Rs.53,290/- asis evident from the inpatient bill dt. 01.07.2011 and it is clear from face of the record that the surgical procedure was performed but the OPs to avoid their legal liability to pay, are harassing the complainants by repudiating the claim of the complainants illegally by citing untenable excuses. Further submitted that the cause of action happened when the OP No.2 sent reply dated 01.03.2012 to the legal notice wherein the claim of the complainants was illegally rejected on frivolous grounds and thus the complainants have filed the present complaint within limitation before the Hon’ble Forum and is well within the jurisdiction of the Hon’ble Forum. The Complainant has prayed to declare letter of repudation dated 06.08.2011 issued by TPA i.e. E-Meditech Services ltd and further reply to legal notice dated 01.03.2012 wherein the claim of the complainants was rejected as null and void being illegal abinitio and also to pay claim of the amount of Rs.70,008/- alongwith interest @ 18% p.a. from 11.07.2011 the day when the medical claim was raised till its realization alongwith compensation. Hence, the present complaint.

2.       Upon notice, OP appeared and filed written statement submitting that the complaint is barred by limitation and alleged treatment in hospital was done on 30.06.2011 & after considering the all medical documents & bills etc the claim was repudiated vide letter dated 06.08.2011. Therefore the limitation starts running from 30.06.2011 & latest by 06.08.2011 when the claim was repudiated. In any case approaching several authorities/offices by way of optional appeal or making representations or by issuing notices the period of limitation does not extend. One cannot take benefit of dates of decision of optional appeals which were decided Divisional office on 23.08.2011 & thereafter North Zone Health Insurance Deptt New Delhi on 15.09.2011. Had the office of OP No.4 kept silent & not decided the claim of the claimants, may be either side & further not respondent to the consumer regarding their decision, then only then the limitation could be taken to be extended on the ground that matter is still pending & the claim has not yet been decided. So, when the claim has been repudiated due to any reason by letter dated 06.08.2011, so in any case the limitation cannot be suo motto extended by drafting lengthy alleged occasions & chain of dates. Hence the complaint in hand deserves to be dismissed on this score alone. Further submitted that as a matter of fact Sh. Ajay Aggarwal, principal insured under the policy took LIC plain No.901 i.e. Health Plus Policy on 26.08.2008 from BO Ambala City. Under the said policy he opted IDB as Rs.1000/- for self & Rs.500/- for his wife Archana Gupta. Accordingly the MSB (Major Surgical Benefit) is Rs.2,00,000/- for PI Ajay Kumar Aggarwal & Rs.1,00,000/- for Smt. Archana Gupta respectively as per the terms and conditions of policy. It is matter of fact & record too that welcome kit being part of policy bond was provided along with policy bond. As per the contents of the para No.2 and 3 of complaint the complainant No.2 suffered from “multiple uterine Fibroid” & for the purpose “Surgery” was done on 30.06.2011. All hospital “treatment”, bills & receipts were submitted to OP NO.1 on 11.07.2011. Further which is a fact that the said claim was repudiated by the TPA i.e. OP No.4 vide letter dated 06.08.2011 on the ground that Surgery not listed in allowed Surgeries and total hospitalization period is less than 52 hours, which is all a per terms and conditions of policy. In other terms to the repudiation is legal & valid too. The complainant in para 7(ii) of the complaint has claimed the procedure of “Multiple Uterine Fibroid” as “Major Surgery”. It is also claimed that they could have remained in the said hospital for more period, but it could not have served any purpose, except to flatten the bill of the hospital, which the insured being prudent man never wnted. Further as per para 12 & Ann. C-7 they clearly stated that nature of Surgery performed is “Uterine Artial Embolization for Fibroids”. The complainant is trying to mislead the Hon’ble Forum by claiming Uterine Artial Embolization for fibroids as Major Surgery. In fact what to talk about major surgery, this technique is not even taken/termed as surgery. The patient may stay in the hospital overnight or may go home the same day. After the procedure the patient is advised to lie plat for 4-6 hours. The claim has been rightly repudiated. So, OPs have prayed for dismissal of the present complaint.

3                 To prove his version complainant tendered his affidavit as Annexure C-X along with documents as annexure C-1 to C-40 and close his evidence. On the other hand, counsel for the Ops has also tendered affidavit as Annexure R-X alongwith documents as Annexure R-1 to R-15 and close his evidence.

4.                We have heard counsel for the parties and carefully gone through the case file. The first contention of the OP is that the present complaint is time barred as the claim of the complainant was rejected vide letter Annexure C-28 dated 23.08.2011 & the present complaint has been filed on 24.09.2013 after period of two years from the date of cause of action and same is time barred.

                   On the other hand, counsel for complainant submitted that letter dated 23.08.2011 Annexure C-28 is not repudiation letter as evident from its contents wherein on the second page of said letter it is specifically mentioned that if insured complainant is not satisfied with the decision of the OP then complainant may send the representation for reconsideration of his claim to our Zonal Office and the complainant has also send representation before Zonal Office on 08.09.2011 i.e. OP NO.2 as per Annexure C-29 and the copy of the same was also endorsed to OP NO.3 and the complainant had also served a reminder on 20.10.2011 to OP NO.2 and the copy was again endorsed to OP No.3 through registered letter Annexure    C-32. After that the OP have sent a letter dated 02.11.2011 as Annexure C-35 in reference to letter dated 20.10.2011 memo No.32 vide which officials of the OPs department has informed the complainant that his representation has been sent alongwith his claim file to Zonal Manager, Life Insurance Corporation of India, New Delhi for necessary action. Thereafter, the complainant also served a legal notice dated 11.02.2012 through his counsel and Senior Divisional of LIC Department had repudiated the claim of the complainant vide letter dated 01.03.2012 and sent the same to the counsel of the complainant as per Annexure C-39. So, the cause of action to file the claim has arisen on 01.03.2012 and present complaint has been filed on 24.09.2013 within limitation period i.e. two years from the date of cause of action as per Section 24 A of the Consumer Protection Act which says that:

                   “The District Forum, the State Commission or the National Commission shall not admit a complaint unless it is filed within two years from the date on which the cause of action has arisen”. It is clear that the present complaint has been filed within limitation from the date of cause of action. Therefore, the contention of the OP regarding present complaint is time barred is hereby rejected”.

                   In the present case, the claim of the complainant was rejected on the two grounds. Firstly is that Surgery undergone of the complainant is not listed as per the list mentioned in Annexure R-3 i.e. terms and conditions of the policy. We have gone through the terms and condition of the Policy i.e. Annexure R-3 which has been strongly relied upon by the OP being their star documents. The perusal of said documents reflected that Surgery i.e. Multiple Uterine Fibroid Undergone by complainant No.2 is neither mentioned in the list of Surgery allowed nor the same is mentioned in the list of disallowed surgery. We have no other option accept to treat the surgery undergone by the complainant No.2 is allowed under the policy and same is not specifically excluded in the list of disallowed Surgery. So contention of the OPs to the effect that surgery undergone by complainant No.2 is not covered under the policy not sustainable in the above said discussion.

                   Now, we are deciding another ground that the total hospitalization period of the surgery is less than 52 hours and the same is mandatory but in the present case, patient was admitted on 30.06.2011 at 7a.m. and was discharged on 01.07.2011 at 10 p.m. & total hospitalization period come to 27 hours.

                   On the other hand, counsel for the complainant argued that the policy was issued to the complainant on 26.08.2008 whereas present policy namely LIC health plus plan was published on 26.12.2008 as per Annexure-A placed on the file at the time of the arguments i.e. Information Available on internet produced by complainant. So, the question of issuance of voucher alongwith policy document on 26.08.2008 does not arise at all & meaning thereby no such condition regarding hospitalization of at least 52 hours was brought into knowledge of the complainant at the time of issuance of the policy. Moreover, as per the guidelines issued by IRDA on 20.02.2013, it is specifically mentioned the minimum period of the hospitalization required is 24 hours whereas in the present case the total hospitalization is 27 hours as per Annexure-B i.e Guidelines issued by Insurance Regulatory and Development Authority. So, the repudiation of claim on the ground of hospitalization of the complainant No.2 is less than 52 hours is also not sustainable in the eye of law and same is hereby rejected. Moreover the said clause even does not appeal to common sense that there must be hospitalization of minimum 52 hours when the treating doctor does not prescribed the same.

                   In view of the above said discussion, we are of the confirmed view that the repudiation Letter dated 01.03.2012 Annexure C-39 is liable to be quashed and same is hereby quashed. In this way, the OPs have withhold the genuine claim of the complainant. Hence, the complainant is entitled the relief and the present complaint is hereby allowed with costs and Ops are directed to comply with the following direction within thirty days from receipt of copy of the order:-

(i)      To pay Rs.70,008/- alongwith interest @ 9% p.a. from the date of the repudiation of the claim i.e. 01.03.2012 till its realization. In case of failure to comply with the order within stipulated period then OPs will liable to pay further interest @ 12% for the default period.

(ii)     Also to pay a sum of Rs. 5,000/- as cost of litigation.

                   Copies of the order be sent to the parties concerned, free of costs, as per rules. File after due compliance be consigned to record room.

Announced on :    14.07.2017.                                                (D.N. ARORA)

                                                                                       President

 

    

     (PUSHPENDER KUMAR)

                                                                                            Member

 

 

              (ANAMIKA GUPTA)

                                                                                            Member