DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, NORTH-WEST
GOVT. OF NCT OF DELHI
CSC-BLOCK-C, POCKET-C, SHALIMAR BAGH, DELHI-110088.
CC No: 594/2016
D.No._______________________ Dated: _______________
IN THE MATTER OF:
DEEPAK KUMAR TYAGI,
S/o LATE SH. DEVENDER KUMAR TYAGI,
R/o B-6/56-57, 2ND FLOOR, SEC.-5,
ROHINI, DELHI-110085. … COMPLAINANT
Versus
NATIONAL INSURANCE CO. LTD.,
(THROUGH ITS CHIEF MANAGER),
DIVISION-XIV, PLOT No. 5-D.P. BLOCK,
2nd& 3rd FLOOR, LSC, OFFICE CODE:360700,
OFFICE NAME: NEW DELHI DIVISION-14,
PITAM PURA, DELHI-110088. … OPPOSITE PARTY
CORAM :SH. M.K. GUPTA, PRESIDENT
SH. BARIQ AHMED, MEMBER
MS. USHA KHANNA, MEMBER
Date of Institution: 13.06.2016
Date of decision: 10.07.2018
SH. M.K. GUPTA, PRESIDENT
ORDER
1. The complainant has filed the present complaint against the OP under Section 12 of the Consumer Protection Act, 1986 therebyalleging thatthe representative/agent/employee of OP approached
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the complainant and induced him for a medical claim policy of the OP and gave assurance and promises to the complainant that OP will indemnify against all the losses, damages and the expenditure incurred by the complainant in diagnosing and treatment of the disease and the complainant before taking policy had an offer to the authorized agent/servant and employee of OP that he is ready and willing to go under any kind of medical check-up in respect of pre-existing disease, if any, but the authorized agent/servant/employee of OP refused for the same. The complainant further alleged that the complainant had taken policy through one person namely Ms. Neena Kumari, an authorized agent of OP and paid the premium for a sum of Rs.4,562/- to OP and OP after acknowledging and receiving the payment from the complainant issued the policy no. 360700/48/15/8500003228 for the period from 28.08.2015 to 27.08.2016 and in the policy cover his wife and daughters are also covered. The complainant further alleged that the complainant all of a sudden suffered the fever on 07.09.2015 and on the diagnosis and medical investigation on 09.09.2015, dengue was deducted in the body of the complainant and the complainant remain under the intensive medical care and treatment the Hemraj Jain Hospital, Pushpanjali Enclave, Pitam Pura, Delhi on 09.09.2015 at 4:30 P.M. and was discharged from the Hospital on 15.09.2015 at 6:00 P.M. under the medical supervision of Dr. Gagan and the complainant
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from his own pocket had spent a sum of Rs.49,000/- approx. The complainant after discharge from the hospital had provided all the original documents of medical treatment, original bills and medical expenditure incurred by the complainant on his treatment to OP on 09.10.2015 and the complainant also provided the certified copy of registration certificate of Hemraj Jain Hospital in which the complainant was admitted. The complainant further alleged that all the original medical treatment documents, history of treatment, bills and expenditure incurred by the complainant is already in power, possession and control of OP. The complainant further alleged that OP since 09.10.2015 and till 05.02.2016 i.e. date of repudiation of claim has never sent any letter, correspondence, information to the complainant asking the complainant to provide any document and information. OP vide its letter dated 05.02.2016, dishonestly, fraudulently and maliciously and without any justified and lawful grounds repudiated the claim of the complainant on false and fabulous grounds.Moreover, the dengue disease is epidemic one and it may be sprouted unexpectedly at any point of time and cannot be called a pre-existing disease and if the dengue patient is not given the timely treatment then it may cause loss of valuable human life at any point of time and the action of the OP in refusing the legal claim amounts to deficiency in service on the part of OP.
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2. On these allegations the complainant has filed the complaint praying for direction toOP to pay total sum of Rs.49,000/- towards the medical expenses incurred alongwith interest @ 12% p.a. w.e.f. 09.10.2015 till the realization of the amount and has also claimed compensation of Rs.50,000/- towards the mental agony and harassment caused to the complainant and has also sought a sum of Rs.21,000/- towards cost of litigation.
3. OP has been contesting the complaint and has filed written statement. In the written statement, the OP submitted that there is no deficiency in service on the part of OP and the complaint is liable to be dismissed. OP further submitted that the complainant purchased the Parivar Mediclaim family policy on 28.08.2015 vide policy no. 360700/48/15/8500003228 in the sum of Rs.2,00,000/- and paid the premium of Rs.4,562/- and policy witnesses that subject to the terms & conditions and the company’s liability would arise to the treatment of disease or injury contracted/suffered is inspected during the policy period and total expenses incurred for any one illness is limited to 50% of sum insured per family. OP further submitted that the company’s liability in respect of all claims admitted during the period of insurance shall not exceed the sum insured mentioned in the schedule and the complainant without full fill the terms & conditions of the policy and hence, there is no cause of action for filing of the present complaint. OP further
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submitted that the complainant was admitted on 07.09.2015 had suffered the fever and on the diagnosis and medical investigation on 09.09.2015 dengue was deducted in the body of the complainant and admitted in Hemraj Jain Hospital, Pushpanjali Enclave, Pitam Pura, Delhi and as per medical treatment the complainant suffered the fever and dengue was deducted and OP further submitted that the complainant did not fulfill the terms & conditions of the policy. OP further submitted that any disease, other than those stated in clause 4.3, contracted by the insured person during the first 30 days from the commencement date of the policy and the condition 4.2 shall not however, apply in case hospitalization of due to accidental injury or if the insured person having been covered under this scheme or a similar Health Insurance Scheme with any of the Indian Insurance companies for a continuous period of preceding 12 months without any break. OP further submitted that TPA Md India Health Care Services Pvt. Ltd. rejected the claim of the complainant on 11.11.2015 on the ground of insured had contracted the disease within 30 days from the inception of first policy, hence, claim is not payable as per terms & conditions of the policy under exclusions 4.1 and OP further submitted that the claim is not maintainable and is liable to be dismissed.
4. The complainant filed replication and denied the submissions of the OP and furthersubmitted that the OP has taken a misleading plea.
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5. In order to prove hiscase the complainant filed his affidavit in evidence and also filed written arguments. The complainant also placed on record copy of insurance policy no. 360700/48/15/8500003228 for the period from 28.08.2015 to 27.08.2016 (mid-night), copy of letter dated 05.02.2016 issued by OP to the complainant, copy of report dated 15.09.2015 issued by One Plus Ultrasound Lab, copy of registration certificate dated 16.04.2014 issued by Directorate of Health Services, GNCT of Delhi, copies of bill/cash no. 420 dated 15.09.2015 of Rs.41,766/-, cash memo no. 5005 dated 09.09.2015 of Rs.1,731.60, cash memo no. 5064 dated 10.09.2015 of Rs.2,283.66, cash memo no. 4524 dated 11.09.2015 of Rs.1,990.70, cash memo no. 4583 dated 12.09.2015 of Rs.1,992.83, cash memo no. 4650 dated 13.09.2015 of Rs.1,948.53, cash memo no. 4688 dated 14.09.2015 of Rs.2,158.52, cash memo no. 4728 dated 14.09.2015 of Rs.305/-, cash memo no. 4758 dated 15.09.2015 of Rs.1,903.12 & cash memo no. 4783 dated 15.09.2015 of Rs.1,268/- issued by Hemraj Jain Hospital Pharmacy, copy of receipt no. 3150 dated 14.09.2015 of Rs. 4,250/- issued by Pitam Pura Blood Bank, copy of discharge certificate dated 15.09.2015 issued by HemrajJain Hospital, copies of laboratory reports no. 1033 dated 09.09.2015, report no. 1045 dated 10.09.2015, report no. 1098, 1120 & 1142 dated 11.09.2015,
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report no. 1153 & 1178 dated 12.09.2015, report no. 1209 & 1218 dated 13.09.2015, report no. 1258 dated 14.09.2015 and report no. 1276 dated 15.09.2015 issued by 02 Care Labs LLP.
6. On the other hand, Ms. Manju Rani, A.O. of OP filed her affidavit in evidence which is on the basis of written statement and OP has also filed written arguments.
7. This forum has considered the case of the complainant as well asOP in the light of evidence and documents placed on record by the parties. The case of the complainant has remained consistent and there is nothing on record to disbelieve the case of the complainant. The documents and evidence of the parties shows that the complainant was hospitalized in Hemraj Jain Hospital during the period from 09.09.2015 to 15.09.2015 for treatment of dengue fever. This fact is not disputed by the OP. The dengue fever is an epidemic disease and cannot be termed by any stretch of imagination that dengue fever is a pre-existing disease.Thus, the OP has taken a false and bogus defenceand in these circumstances, this forum is of opinion that OP was not justifiedin denying the claim of the complainant. Thus, OP is held guilty of deficiency in service.
8. Thus, holding guilty for the same, we direct the OP to: -
-
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purchase of medicines and undergoing tests/examination alongwith interest @ 12 p.a. w.e.f. 09.10.2015 till the date of this order.
ii) To pay to the complainant an amount of Rs.25,000/- as compensation for harassment and mental agony suffered which includes litigation cost.
9. The above amount shall be paid by OP to the complainantwithin 30 days from the date of receiving copy of this order failing which OP shall be liable to pay interest on the entire awarded amount @ 10% perannum from the date of receiving copy of this order till the date of payment. If OP fails to comply with the order within 30 days from the date of receiving copy of this order, the complainant may approach this Forum u/s 25 of the Consumer Protection Act, 1986.
10. Let a copy of this order be sent to each party free of cost as per regulation 21 of the Consumer Protection Regulations, 2005. Thereafter file be consigned to record room.
Announced on this 10th day of July, 2018.
BARIQ AHMED USHA KHANNA M.K. GUPTA
(MEMBER) (MEMBER) (PRESIDENT)
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