Delhi

North East

CC/231/2015

Chander Parkash Nagpal - Complainant(s)

Versus

M/s New India Assurance Company - Opp.Party(s)

06 Nov 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION: NORTH-EAST

GOVT. OF NCT OF DELHI

D.C. OFFICE COMPLEX, BUNKAR VIHAR, NAND NAGRI, DELHI-93

Complaint Case No. 231/15

In the matter of:

 

	1.         2.	Sh. ChanderPrakashNagpal (since deceased) through LRs namely- Smt. MamtaNagpal W/o Lt. Sh. ChanderPrakash R/o 283/3, New Layalpur, DikshitGali, Delhi-110051   Sh. KunalNagpal, S/o Lt. Sh. ChanderPrakash, R/o 283/3, New Layalpur, DikshitGali, Delhi-110051 (LRs of Sh. ChanderPrakash, now deceased)		Complainants
		Versus
		New India Assurance Co. Ltd. Through its General Manager, 487, 2nd Floor, Zulfa Bengal, G.T. Road, Dilshad Garden,		Opposite Party
			DATE OF INSTITUTION:            02.07.2015  JUDGMENT RESERVED ON:    06.06.2023   DATE OF ORDER:                       06.11.2023		02.07.15 06.06.23 06.11.23

 

CORAM:

Surinder Kumar Sharma, President

Anil Kumar Bamba, Member

Adarsh Nain, Member

 

ORDER

 

Ms. Adarsh Nain, Member

The Complainant (now deceased) filed the present complaint under Section 12 of the Consumer protection Act, 1986 against the Opposite Party.Sh. ChanderPrakashNagpal was the original complainant and died during pendency of the present complaint. Smt. MamtaNagpal (widow) and Sh. KunalNagpal (Son of the deceased) being legal heirs of the deceased were impleaded as the application in that regards were allowed by the predecessor commission vide order dated 19.02.2019.

Case of the Complainant

1. The case of the Complainants as revealed from the record is that the deceased Complainant had purchased a mediclaim policy first time in the year 1999 and was continuously insured till the year 2012. The policy was renewed on 27.09.12 vide policy no. 32030334120100000286 with enhanced sum insured of Rs. 3,00,000/-It was stated that on 23.10.2012, the Complainant felt the pain in lower abdomen and admitted to the hospital R.G. Urology and Laproscopy Hospital and was discharged after getting necessary treatment. The medical expenses incurred in the said treatment were cleared by the Opposite Party. The complainant policy was again renewed for the period 27.09.2013 to 26.09.2014 for the enhanced sum insured of Rs.5,00,000/-. In the month of October 2013, the complainant againfelt the pain in lower abdomenand difficulty in passing the urine and Complainant got hospitalized inPushpanjaliCrossley Hospital, Ghaziabad, U.P. Thereafter, the said hospital immediately wrote letter for authorisation of treatment and guarantee for payment toTPA who sanctioned the authorization and sanctioned the guarantee of payment up to Rs. 80,000/- at the initial stage. The doctors diagnosed the case of Carcinoma Prostate which required the Radiotherapy Treatment by IGRT Technique but the TPA of the Opposite Party approval for IMRT Technique. The doctor again requested the TPA for approval for IGRT Technique. All the queries raised by the TPA from time to time were cleared. On 10.10.13 the TPA further authorized for Rs. 20,000/- more. Hence the total authorization letter for treatment was given to the hospital to the tune of Rs. 1,00,000/-.The treatment of radiotherapy was started on 14.10.13 and completed on 17.12.13. The hospital raised the bill of Rs. 1,77,000/- andtheTPApaidRs. 1,00,000/- to the hospital. The complainant was forced to pay the balance amount of Rs. 77,000/-.After making the payment, Complainant lodged claim with TPA as well as Opposite Party. The Complainant stated that despite continuous request for payment of his claim the Opposite Party was not ready to clear the claim of Complainant. The TPA agreed to pay sum of Rs.25,000/- to Complainant through his letter dated 11.08.14. The Complainant stated that remaining Rs.77,000/- were not paid by the Opposite Party.Hence, this shows deficiency in service on behalf of Opposite Party. The Complainant has prayed for Rs. 5,00,000/- for mental harassment and Rs. 50,000/- on account of transportation and computer services to write regularly mail to the Opposite Party. He also prayed for interest @ 24 % on Rs. 77,000/- i.e. Rs. 27,720/- from the date of payment which is 18.12.2013 and Rs. 25,000/- towards litigation.

 

 

Case of the Opposite Party

2. The Opposite Party was served with the notice of the complaint but none has appeared on behalf of Opposite Party.  Therefore, Opposite Party was proceeded against Ex-parte vide order dated 14.10.15. However, the said order was set aside by Hon’ble State Commissionvide order dated 04.09.19 and the Opposite Party was allowed to file its reply subject to payment of Rs.4,000/- as cost.The Opposite Party filed its written statement and stated that while admitting that the sum insured prior to 2012 was 1,00,000/-and it was enhanced to 3,00,000/- in the year 2012 and further to Rs.5,00,000/- in 2013, contends that under the terms and conditions of the policy, the enhancement of the sum insured was subject to the exclusions. It is submitted that as per those exclusions, enhanced sum was not applicable as the claim was for a pre-existing disease and the insured (Now deceased) was covered for a sum of Rs. 1,25,000/-only under the policy as per clause 5.11 of the terms and conditions of the policy. The Opposite Party prays for dismissal of the complaint for being baseless and unsustainable in law.

Rejoinder to the written statement of Opposite Party

3. The Complainant filed rejoinder to the written statement of Opposite Party wherein the Complainant has denied the pleas raised by the Opposite Party and has reiterated the assertion made in the complaint.

 

 

Evidence of the Complainant

4. The Complainant (since deceased) in support of his complaint filed his evidence by way of affidavit wherein he had supported the averments made in the complaint.

Arguments & Conclusion

5. We have heard the Ld. Counsels for the parties.We have also perused the file and the written arguments filed by the parties.
6. It is the case of the Complainants that Complainant (now deceased) was continuously insured with Opposite Party under health policy till the year 2013 with enhanced sum insured of Rs. 5,00,000/-. As the insured complainant was diagnosed with cancer, the treatment of radiotherapy was started on 14.10.13 and completed on 17.12.13. The hospital raised the bill of Rs. 1,77,000/-. It is alleged that the Opposite Party only paid Rs. 1,00,000/- to the hospital and Complainant was forced to pay the balance amount of Rs. 77,000/-.It is alleged that the remaining balance of Rs.77,000/- was not paid by the Opposite Party and committed deficiency of services.
7. While on the other hand, the contention of the Opposite Party is that under the terms and conditions of the policy, the enhancement of the sum insured was subject to the exclusions. It is their case that on the date of operation the deceased insured was covered under previous policy and the enhanced sum was not applicable as the claim was for a pre-existing disease and the insured (Now deceased) was covered for a sum of Rs.1,25,000/-only under the policy as per clause 5.11 of the terms and conditions of the policy.
8. It is not disputed that the insured Complainant (Now deceased) was continuously insured with the Opposite Party and it is also not is dispute that the Opposite Party renewed the policy time to time and enhanced the sum insured to Rs.5,00,000/- till year 2013.
9. The contention of the Opposite Party is that the enhanced sum insured was not applicable becauseas per clause 5.11 of the terms and conditions of the policy, the enhancement of the sum insured was subject to exclusions 4.1,4.2 & 4.3 and the claim of the Complainant being for treatment of pre-existing disease was covered for a sum of Rs.1,25,000/-.
10. The Opposite Party has relied upon clause 5.11 of the terms and conditions of the Mediclaim policy 2012, which provides as follows

“ 5.11 Enhancement of sum insured

You may seek enhancement of sum insured in writing before payment of premium for renewal, which may be granted at our discretion. Before granting such request for enhancement of sum insured, we have the right to have you examined by a Medical Practitioner authorized by us or the TPA. Our consent for enhancement of sum insured is dependent on the recommendation of the Medical practitioner and subject to limits as per table in Annexure I.

Enhancement of sum insured will not be considered for:

1. Insured persons over 65 years of age.
2. Insured person who had undergone more than one Hospitalisation in the preceding two years.
3. Insured person suffering from one or more of the following illnesses/conditions:

A. Diabetes

B. Hypertension

C. Any chronic Illness/ailment

D. Any recurring Illness/ailment

E. Any critical Illness.

In respect of any enhancement of sum insured, exclusions 4.1, 4.2 and 4.3 would apply to the additional sum insured from such date.”

 

11. The plain reading of above noted clause shows that Opposite Party had the discretion to grant the enhancement and had right to examine the insured by a medical practitioner whose recommendations were to form the basis for consent for such enhancement.
12. It is an admitted fact that the sum insured was enhanced by the Opposite Party to Rs.5,00,000/- in case of the Complainant. The perusal of the record shows that Opposite Party did not bother to get the Complainant insured examined medically as is required under the terms of the policy. In such case, Opposite Party cannot be allowed to take shelter under the said clause and take the stand that the enhanced sum is not applicable and pay the otherwise genuine claim partly under the previous policy.
13. Therefore, in view of the above discussion, we are of the considered opinion that the Opposite party has been deficient in services by not paying the balance amount of the genuine claim of the Complainant, causing mental agony and torture to the Complainant
14. Accordingly, we allow the complaint and direct the Opposite Party to pay the balance amount of Rs. 77,000/-with interest @ 9% p.a. from the date of payment which is 28.10.2013 till recovery. Opposite party is further directed to pay Rs.50,000/- towards compensation and Rs. 25,000/- as litigation cost. Opposite Party is liable to pay the same within a period of 4 weeks from the date of receipt of order. In case of delay in the payment beyond 4 weeks Opposite Party will be liable to pay interest @9% p.a. for the delayed period.
15. Order announced on 06.11.23.

Copy of this order be given to the parties free of cost.

File be consigned to Record Room.

(Anil Kumar Bamba)           Member

(Adarsh Nain) Member

(Surinder Kumar Sharma) President