District Consumer Disputes Redressal Commission ,Faridabad.

Consumer Complaint  No. 537/2022.

 Date of Institution:30.09.2022.

Date of Order:12.07.2023.

Ms. Sandhya Sharma D/o Sh. Tilak Raj Sharma R/o House No. 1717, Sector-8, Faridabad, Haryana.

                                                          …….Complainant……..

                                                Versus

1.                M/s. National Insurance Company Limited, Faridabad, Divisional Office-1, 5C/1-2, B.P,Railway Road, Neelam Chowk, NIT, Faridabad, Haryana – 121001.

2.                M/s. Safeway Insurance TPA Pvt. Ltd., HO-815, Vishwas Sadan, District Centre, Janak Puri, New Delhi – 110 058 through its Managing Director/Directors.

3.                M/s. Save Sight Centre, A-14, G.T.Karnal Road, Adarsh Nagar, Delhi – 110 033 through its Director.

                                                                              …Opposite parties

BEFORE:            Amit Arora……………..President

Mukesh Sharma…………Member.

Indira Bhadana………….Member.

PRESENT:                   Sh. Atul Khatri,  counsel for the complainant.

                             Sh. Sumit Singh, counsel for opposite parties Nos.1 & 2.

                             Opposite party No.3 exparte vide order dated 13.2.2023.

ORDER:

                             The facts in brief of the complaint are that the complainant being induced by the representative/agent of the opposite parties Nos.1 & 2 purchased one Health Insurance Policy bearing policy No. 361100502110001925 period of insurance from00.00 hrs of 13.06.2021 to midnight on 12.06.2022 issued by  opposite party No.1.  The above said policy was in continuation of previous insurance policies issued by the opposite parties which were held by the complainant since last 8 years i.e. 2014-15 and duly acknowledged by the opposite parties Nos.1 & 2 while accepting current year policy  Thus the opposite parties had issued the present policy while confirming to the previous policies issued by the opposite parties which was held by the complainant since last 8 years i.e 2014-15.   On 31.5.2022 the complainant had visited to the opposite party No.3 due to problem in both eyes.  Upon investigations, the treating doctor of opposite party No.3 hospital diagnosed  refractive error in both eyes of the complainant and advised Lasik surgery for the same.  In pursuant of the same advice, the complainant intimated the opposite parties Nos1 & 2 about the surgery and admitted in opposite party No.3 hospital where FEMTO Lasik surgery with Topoguided contour in both eyes was performed upon the  complainant which improves the condition of eyes of the complainant and the complainant was discharged in a stable condition on 31.05.2022.  Against the entire treatment, a bill of Rs.70,000/- were issued by opposite party No.3 hospital which was duly paid by the complainant.  Before the surgery, the complainant asked the opposite party about cashless facility for the same but the same was denied and asked for re-imbursement after the surgery.  After getting discharged from the opposite party No.3 hospital, complainant applied for re-imbursement of claim while submitting the entire final bill alongwith the treatment records to opposite parties Nos.1 & 2 with a request to honour the entire claim, but opposite parties Nos.1 & 2 had ejected the re-imbursement claim of the complainant under 4.2(a) of the policy while saying that 2 years of waiting period to cover this treatment had not been completed and told that “Expenses related to treatment for refractive error of the eye more than 7.5 dioptres should be excluded until the expiry of 2 years of continuous coverage after the date of inception of the first policy with us”  Thereafter, the complainant tried to make opposite parties Nos.1 & 2 understand that it was not her pre-existing disease and her policy inception date was since 2014 with them, so waiting period of 2 years for this disease had already been covered and there was no question of waiting period of 2 years for this disease as alleged by them, hence the repudiation of claim was illegal unlawful by them, but opposite parties Nos.1 & 2 did not accede to the request made by the complainant and didn’t honour the re-imbursement of claim submitted by the complainant.  The  complainant had conveyed them about the latest guidelines issued by Insurance Regulatory and development Authority (IRDAI) about the exclusions that were applicable on all indemnity-based policies which says that if the patient had a refractive error of 7.5 dioprates or more, his/her refractive surgery was included under the health insurance policy.  Thereafter, time and again complainant requested the opposite parties Nos.1 & 2 to consider the claim of the complainant and to honour her claim, but no claim was honoured by opposite parties Nos.1 & 2 and rejected the same arbitrarily on the ground of non-completion of waiting period for this disease which was otherwise wrongful, errorless decision by the opposite parties Nos.1 & 2 company as the policy defines specified disease/procedure waiting period as “Expenses related to treatment for Refractive error of the eye more than 7.5 dioptres shall be excluded until the expiry of two years of continuous coverage after the date of inception of the first policy with us”.

Thus, the first policy inception date was 2014-15, hence the waiting period of 2 years had already been elapsed in complainant case  Thereafter, complainant approached the opposite parties and tried to make them understand that they had wrongly interpreted the non completion of waiting period by themselves which otherwise not applicable in her case, but nothing avail.  Needless to mention that complainant had also shown all previous years policies since the year 2014 and requested them to honour the claim, but opposite parties Nos.1 &2 abruptly rejected the complainant claim,The aforesaid act of opposite party amounts to deficiency of service and hence the complaint.  The complainant has prayed for directions to the opposite party to:

a)                reimbursement claim of Rs.70,000/- being treatment bill alongwith interest @ 18% per annum from the date of illegally rejected claim till the date of payment thereof.

 b)                pay Rs.2,00,000/- as compensation for causing mental agony and harassment .

c)                Any other relief which this Hon’ble Forum may deem fit and proper in the circumstances of the complainant may also be granted in favour of the complainants and against the opposite parties.

2.                Opposite party put in appearance through counsel and filed written statement wherein Opposite parties Nos.1 & 2 refuted claim of the complainant and submitted that  opposite parties issued a health insurance policy bearing No. 361100502110001925 covering period from 13.06.2021 to 12.06.2022.   On the basis of above said insurance policy the complainant had submitted her claim with the answering opposite parties, alleging therein that as he remained under treatment at Save Sight Centre, A-14, G.T.Karnal Road, Adarsh Nagar, Delhi, on 13.05.2022 for the purpose of treating her both eyes and for which she had to spent a sum of Rs.70,000/-.  As per the clause 4.2 of the New Revised Policy “On scrutiny of the final documents, it was found that the patient Sandhya Sharma was admitted in sAve Sight Centre on 31.5.2022, as a diagnosed case of Refractive Error in both eyes and managed surgically.  As per given documents, patient underwent FEMTO LASIK surgery, which had a waiting period of 02 years but insured was covered in the new revised policy (in which this treatment was covered) only since 13.06.2020 (i.e. 02 years waiting period to cover this treatment had not been completed).   Hence, the claim was repudiated as per clause 4.2 of the policy (a) specified disease/procedure waiting period, which states that “expenses related to the treatment for Refractive error of the eye more than 7.5 dioptres shall be excluded until the expiry of two years of continuous coverage after the date of inception of the first policy with us.” Opposite parties Nos.1 & 2 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.

3.                Notice issued to opposite party No.3 on dated 09.01.2023 not received back either served or unserved.  Tracking details filed in which it had been mentioned that “Item Delivery confirmed”.  Mandatory period of 30 days expired.  Hence, opposite party No.3 was hereby proceeded against exparte vide order dated 13.02.2023.

4.                The parties led evidence in support of their respective versions.

5.                We have heard learned counsel for the parties and have gone through the record on the file.

6.                In this case the complaint was filed by the complainant against opposite parties–National Insurance Co. Ltd.. with the prayer to: a)  reimbursement claim of Rs.70,000/- being treatment bill alongwith interest @ 18% per annum from the date of illegally rejected claim till the date of payment thereof.  b) pay Rs.2,00,000/- as compensation for causing mental agony and harassment .

                    To establish his case the complainant  has led in his evidence,  Ex.CW1/A – affidavit of Sandhya  Sharma,, Ex.C1 health card, Ex.C-2 – national mediclaim Policy prospectus, Ex.C-3 – Discharge summary, Ex.C-4 – Bill cum receipt, Ex.C-5 – Retail invoice, Ex.C-6 – email, Ex.C-7 – repudiation letter, Ex.C-8 – legal notice,, Ex.C-9 to 11 – postal receipts,

                   On the other hand counsel for the opposite parties strongly agitated and opposed.  As per the evidence of the opposite parties  Ex.RW1/A – affidavit of Dharmender  Arya, AM, National Insurance Company Ltd. , Ex.R1 – “Revision of “National Medicalim policy. Ex.R-2 – Insurance terms & conditions

7.                After going through the evidence led by the parties,  the Commission is of the opinion that the complaint is allowed. Opposite parties, jointly & severally, are directed to process the claim of the complainant within 30 days from the date of receipt of the copy of order and pay the due amount to the complainant alongwith interest @ 6% p.a. from the date of filing of complaint  till its realization.    Opposite parties are also directed to pay Rs.2200/- as compensation for causing mental agony  & harassment alognwith  Rs.2200/- as litigation expenses to the complainant.  Compliance of this order  be made within 30 days from the date of receipt of copy of this order.  File be consigned to the record room.

Announced on:  12.07.2023                                         (Amit Arora)

                                                                                             President

                     District Consumer Disputes

           Redressal  Commission, Faridabad.

                                                             (Mukesh Sharma)

                Member

          District Consumer Disputes

                                                                                  Redressal Commission, Faridabad.

                                                        (Indira Bhadana)

                Member

          District Consumer Disputes

                                                                                   Redressal Commission, Faridabad.