DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II
Udyog Sadan, C-22 & 23, Qutub Institutional Area
(Behind Qutub Hotel), New Delhi-110016
Case No.510/2013
Sh. Nand Kishore Chug, (Senior Citizen)
S/o Sh. Sadhu Ram Chug, 64 years old
R/o D-72, East of Kailash,
New Delhi – 110065. ….Complainant
Versus
M/s National Insurance Co. Ltd.
Through its Chairman/Manager,
Branch Office – E-13, Hauz Khas Market,
New Delhi - 110016. ….Opposite Party
Date of Institution : 04.10.13 Date of Order : 25.04.18
Coram:
Sh. N.K. Goel, President
Ms. Naina Bakshi, Member
ORDER
The complainant filed the present complaint. OP was proceeded exparte. The complainant filed the exparte evidence.
Vide order dated 25.06.14, our Predecessors allowed the complaint and directed the OP to make the payment as detailed in the order.
The OP filed First Appeal No.739/14 before the Delhi State Commission and vide order dated 21.04.17 the Delhi State Commission set aside the order and remanded the case back to this Forum with liberty to the OP to file a written statement and a direction to this Forum to proceed further in the matter in accordance with law. That is how the complaint is again before us.
The case of the complainant, in nutshell, is that he had purchased Hospitalization Benefit Policy bearing No. 360902/48/12/8500000441 for the period 19.06.12 to 18.06.13 for a sum assured of Rs.5 lacs from the OP and the complainant paid a premium of Rs.17,947/-. On 20.02.13, he was admitted in G. B. Pant Hospital for heart disease where he was given treatment and he infact incurred an amount of Rs.6,50,000/- on his treatment which was paid to the G. B. Pant Hospital vide challan No. 478/02 dated 23.02.13. After discharge from the hospital on 08.03.13 he made his claim before the OP and the OP paid Rs.1,03,700/- on 17.05.13 and 04.06.13 directly to the hospital but did not pay the remaining amount of Rs.3,96,300/- to the complainant . Therefore, pleading deficiency in service and unfair trade practice on the part of the OP the complainant has filed the present complaint for issuing directions to the OP to pay to him Rs.3,96,300/ towards the claim amount, Rs.1 lac for causing mental torture etc. and Rs.15,000/- towards litigation cost.
OP has filed a written statement. Paras No. 3 to 9 of the preliminary objections of the written statement of the OP are relevant. They are reproduced as hereunder:-
“3 That the complainant purchased a Hospitalization Benefit Policy for himself and his wife for a period of 19.06.2008 to 18.06.2009 for a sum insured of Rs.1,50,000/- (Rupees One Lakh Fifty Thousand Only). The said policy was again renewed for the period of 19.06.2009 to 18.06.2010 with an enhanced sum insured of Rs.75,000/- (Rupees Seventy Five Thousand Only). The said policy was again renewed on 19.06.2010 for a sum of Rs.25,000/- (Rupees Twenty Five Thousand Only) each and then on 19.06.2011 for a sum of Rs.75,000/- (Rupees Seventy Five Thousand Only) each. It is pertinent to mention here that the Insurance Policy was granted subject to terms, conditions and stipulations as stated in the policy.
4. That during the pendency of the policy, the complainant who was already a known case of Diabetes, Mellitus and Hypertension for more than five years and the complainant was admitted in several hospitals like G.B. Pant Hospital, Pushpanjali Crosslay Hospital, National Heart Institute etc. for Severe Heart Ailment like severe Left Ventricular Systolic Dysfunction and the heart was working only to the extent of 20-25% on 23.02.2013.
5. That the claim was paid by the Opposite Party as per the terms and conditions of the policy. It is submitted that as per the clause 1.0 (c) maximum limit per illness is 50% of the sum insured (Rs.1,50,000/- plus cumulative bonus of Rs.5000/-) for expenses on Anesthesia, Blood, oxygen, O.T. Charges, Surgical Appliances, Medicines, Drugs, Diagnostic Material, X-ray, Dialysis, Cost of pace maker, Artificial Limb, Cost of Stent and Implant. Clause 1 of the Schedule deals with how the claim has to be paid under different headings. It is submitted that as per clause 4.1 of the policy terms and conditions any disease which is pre existing will be covered only after 4 continuous claim free policy years.
6. That it is respectfully submitted that in the present case the sum insured for the period of 2008 to 2009 was Rs.1,50,000/- (Rupees One Lakh Fifty Thousand Only) that will be taken as the sum insured for any of the claims pertaining to the ailments relating to Diabetes Mellitus or Hypertension or their compensation. In the present case both the disease were pre existing prior to 2008 as mentioned in the Investigating Report provided by the TPA, Medi Assistant, complainant had a history of Effect of Diabetes (DM) since 8 years, Hypertension (HTN) since 5 years and Coronary Artery Disease (CAD) since 6-7 years. Furthermore as per clause 5.12 of the policy, where the policy is renewed and the sum insured is enhanced any continuing or recurrent nature of the disease which was insurer/complainant has ever suffered will be excluded from the scope of the cover so far as the enhancement of the sum insured is considered.
7. That it is submitted that as per the terms of the policy the enhanced sum insured cannot be considered for the purpose of the present claim where the ailments were because of Diabetes Hypertension or their related complications. Hence the claim filed by the complainant is bad in eyes of law and is not maintainable and the complaint is liable to be dismissed.
8. It is submitted that the claim was processed taking the basic sum insured as Rs.1,50,000/- (Rupees One Lakh Fifty Thousand Only) and as per that the entire hospital charges were paid, Rs.77,500/- (Rupees Seventy Seven Thousand Five Hundred Only) being 50% of the sum insured plus Rs.5000/- (Rupees Five Thousand Only) as Cumulative Bonus was also paid to the complainant.
9. It is further submitted that Insurance policies issued by the opposite party are valid policies which have been admitted by the complainant and the claim amount as per the term of the policy has been paid to the complainant hence no deficiency under Consumer Protection Act, 1986 is attributed against the opposite party.”
OP has prayed for dismissal of the complaint.
Complainant has not filed any rejoinder/replication to the written statement of the OP and has adopted the affidavit filed in exparte evidence. Affidavit of Sh. Raghunath Pawar, Administrative Officer (Legal) has been filed in evidence on behalf of the OP.
Written arguments have been filed on behalf of the complainant.
We have heard the oral arguments advanced at the bar and have also carefully gone through the record.
At this stage, we record with anguish and sorrow that on 11.10.17 the affidavit of Sh. Raghunath Pawar, Administrative Officer (legal) was filed on behalf of the OP in evidence but, however, the documents filed therewith were illegible. Legible copies of the documents were directed to be filed on behalf of the OP subject to payment of Rs.1000/- as costs to the complainant failing which these documents shall be not taken into consideration while disposing of the case on merits. On the next date i.e. on 23.11.17 counsel for the OP was stated to be suffering from viral fever. On 03.01.18 an adjournment was again sought for compliance of the direction contained in the order sheet dated 11.10.17 and payment of cost. Again on 26.02.18 neither the cost was paid nor the legible copies were filed. On the next date i.e. on 06.04.18 the counsel for the OP did not appear. However, adjournment was sought which was strongly opposed. The opposition was quite justified. Therefore, we observed that illegible documents filed on behalf of OP shall not be read in evidence. It is not out of place to mention here that the costs were also not paid. Arguments on behalf of the complainant were heard on 17.04.18. Arguments were addressed on behalf of the OP on 18.04.18.
This conduct exhibited on behalf of the OP which is a Nationalized Insurance Company is quite pathetic, irresponsible and reprehensible.
Reliance has been placed on behalf of the OP on clauses 1(c), 4.1 and 5.12 of the terms and conditions of the Mediclaim Insurance Policy (Individual). They are reproduced as hereunder:-
“1.0 In the event of any claim/s becoming admissible under this Scheme, the Company will pay to the insured person the amount of such expenses as would fall under different heads mentioned below and as are responsible and necessary incurred by or on behalf of such Insured Person but not exceeding the Sum Assured in aggregate mentioned in the Schedule hereto.
C. Anesthesia, Blood, Oxygen, OT charges, Surgical appliances, Medicines, drugs, Diagnostic Material & X-Ray, Dialysis, Chemotherapy, Radiotherapy, cost of pacemaker, artificial limb and cost of stent and implant. Maximum limit per illness – 50% of Sum insured.
4. Exclusions
The Company shall not be able to make any payment under this policy in respect of any expenses whatsoever incurred by any person in connection with or in respect of:
4.1 All diseases/injuries which are pre – existing when the cover incepts for the first time.
However, those diseases will be covered after four continuous claim free policy years. For the purpose of applying this condition, the period of cover under Mediclaim policy taken from National Insurance Company only be considered.
5.12 Sum insured under this policy can be enhanced only at the time of renewal up to next higher slab if Sum Insured under expiring policy is upto Rs.1,00,000/- and next two higher slabs.. (not legible). Insured under expiring policy is above Rs.1,00,000/- subject to satisfactory medical checkup with regard to health of the insured person and acceptance of additional premium for the enhanced sum Insured. However, continuing or recurrent nature of diseases/complaints which the insured has ever suffered will be excluded from the scope of cover so far as enhancement of Sum Insured.
Copies of the policies in question are also not legible. However, we have tried to gather the real facts from the perusal of the illegible copies. First policy was taken by the complainant for himself and his wife valid from 19.06.08 to 18.06.09 against a premium of Rs.9729/- and the sum insured was Rs.1,50,000/- each. The next policy was for the period 19.06.09 to 18.06.10, premium is shown as Rs.14,020/- and the insured amount increased perhaps to Rs.1,50,000/- plus Rs.75000/- each. The third policy was for the period 19.06.10 to 18.06.11. The total amount of the premium charged was Rs.15378/- and the insured amount has been shown as Rs.2,25,000/-, plus Rs.25,000/- each. The fourth policy was for the period 19.06.11 to 18.06.12 and the net premium is shown as Rs.22,145/- and the sum insured has been shown as Rs.25000/- plus Rs.225000/- plus Rs.75000/-. The fifth policy is the policy in question for the period 19.06.12 to 18.06.13 and the premium amount has been shown as Rs 29620/- and the insured amount as Rs.75,000/- plus Rs.25,000/- plus Rs.2,25,000/- plus Rs.1,75,000/- each.
Admittedly, the complainant fell ill on 20.02.13 and got treatment for heart ailment from G. B. Pant Hospital between 20.02.13 and 08.03.13. Thus, the said ailment of the complainant was during the continuance of the 5th insurance policy continuously being taken from the OP. Therefore, in our considered opinion, the case of the complainant does not fall within the mischief/prohibition contained in the clause 4.1 of the terms and conditions of the insurance policy in question because the said clause 4.1 deals with all the diseases/injuries which are pre-existing and arise within first 4 continuous insurance policies as stated hereinabove. The said disease had occurred to the complainant during the continuance of the 5th insurance policy.
The complainant might have been suffering from Diabetes, Hypertension & Coronary Artery Disease for the last more than 5/6/8 years as stated in the written statement. However, as stated above, the disease in question had occurred to him during the continuance of the 5th insurance policy and, hence, the bar contained in the clause 4.1 was not attracted to the facts of the present case. Therefore, the said contention raised on behalf of the OP is without any substance and is rejected.
It is further submitted on behalf of the OP that the claim was processed by taking the basic sum assured as Rs.1,50,000/-. We are not able to understand any logic behind taking the basic sum assured as Rs.1,50,000/-. We have already described the details of the insured amounts of the five insurance policies. It was the first insurance policy which had the sum assured of Rs.1,50,000/- and the premium of Rs.9729/-. Thereafter, with the renewal of each policy the amount of premium was increased by the OP and similarly the sum assured was also increased. The 5th policy in question for the period 19.06.12 to 18.06.13 was for a total amount of Rs.75,000/- plus Rs.25,000/- plus Rs.2,25,000/- plus Rs.1,75,000/- totalling to Rs.5 lacs. Thus, in our considered opinion, this sum assured of Rs.5 lacs was the insured amount which was to be taken into consideration by the OP while dealing with the claim of the complainant. However, the OP did not do so and, hence, committed serious deficiency in service. Therefore, we hold that the OP was liable to pay the sum assured of Rs.5 lacs to the complainant against his total claim of Rs.6,50,000/-. Hence, we hold the OP guilty of gross deficiency in service.
In view of the above discussion, we allow the complaint and direct the OP to pay Rs.3,96,300/- (Rs.5 lac minus Rs.1,03,700/-) towards the claim amount alongwith interest @ 5% per annum from the date of filing of the complaint till realization to the complainant and Rs.75,000/- for causing mental torture, pain etc. and Rs.10,000/- towards litigation cost.
The order shall be complied within 30 days of receipt of copy of this order failing which OP shall become liable to pay interest @ Rs.6% per annum on the amount of Rs.3,96,300/- 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 25.04.18.
