Delhi

North East

cc/905/2014

Smt Pramila Sharma - Complainant(s)

Versus

M/s Oriental Insurance Co. Ltd. - Opp.Party(s)

29 Nov 2024

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. 905/14

 

 

 

In the matter of:

 

	1.     2.	Smt. Pramila Sharma W/o Lt. Sh. Suresh Chand Sharma   Ms. Srishti Sharma D/o Lt. Sh. Suresh Chand Sharma   Both R/o D 65, West Jyoti Nagar Ext. Delhi		Complainants
		Versus
	1.                   2.	The Oriental Insurance Co. Ltd. Through its Manager Having its Office at:- Oriental House A 25/27, AsalAli Road, New Delhi 110002   Also at:- Raj Block, Naveen Shahdara, Delhi 110032   M/s E.Meditek (TPA Service Ltd.) Having its Office at:- 577 UdyogVihar, Ph.5, Gurgaon Haryana		Opposite Parties
			DATE OF INSTITUTION:         JUDGMENT RESERVED ON:                           DATE OF ORDER:		04.12.2014 08.08.2024 29.11.2024

 

CORAM:

Surinder Kumar Sharma, President

Ms. Adarsh Nain, Member

ORDER

Surinder Kumar Sharma, President

The Complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 against Opposite Party.

Case of the Complainant                                                                 

1. The case of the Complainant as revealed from the record is that the husband of Complainant purchased one mediclaim insurance policy vide office code 271702 on 08.04.11 which was effective from 11.29 AM to mid night of 07.04.12. The same was further extended from 08.04.12 to mid night of 07.04.13 for a sum of Rs. 3,00,000/- upon which a premium of Rs. 9,480/- was fixed and therefore the same was paid accordingly through the Opposite Party No.2. On 16.06.12 the husband of Complainant Sh. Suresh Chand Sharma, the insurance policy holder was admitted in City Hospital. Thereafter he was transferred on 30.06.12 to Sir Ganga Ram Hospital as per the medical advice. After receiving of the discharge bills, Complainant duly submitted the same along with its enclosures in original claiming the mediclaim for sum of  Rs. 1,08,356/- and Rs. 2,02,849/-.The claimant was surprised to know that sum of Rs. 95,855/- was allowed and paid but the remaining claim was repudiated thereafter claimant requested many times in writing vide her written requests on different dates but claim of claimant could not be considered positively and therefore repudiated without application of mind stereotypely vide written communication dated 14.12.12, 14.02.13 and lastly on 22.03.13. At the time of selling the mediclaim policy, the husband of the claimant was got medical examined by the penal doctor of the Opposite Party. The said medical report nowhere reveal a disqualification to purchase the mediclaim policy nor the same is indicated to debar the Opposite Parties from selling the medical by you with our TPA M/s E-meditek.  It was also observed that he was admitted in City Hospital for the C/O Type II Diabetes Mellitus, Diabetic retinopathy, Hypertension, Anaemia, Multifactorial, Chronic Kidney disease (Diabetic Kidney disease) infective myosites. Since as per policy terms and conditions, Diabetes has a waiting period of 2 years from policy onset patient’s policy is a second year policy, hence claim is repudiated. Opposite Parties are under legal obligation  to pay the medical claim, many more objections are being raised with a sole motive to digest the mediclaim of the claimant, particularly in such a circumstances when the claimant has lost her husband on 16.10.12 and therefore, has been facing financial crisis to run her family.  The repudiation of the medicalim of the claimant against the mediclaim policy is arbitrary and illegal on the part of the Opposite Party No.1. For the promotion of their business, the representatives of the Opposite Parties used to explain something and at the time of settling the mediclaim, the office of the Opposite Parties explain something else, which are contrary to each others. Thereafter many more written requests were submitted in very peculiar circumstances but on receipt of said communication, stereotype reply repudiating the claim of the claimant was apprised without assigning appropriate reasons.  The Complainant/claimant requested in writing various correspondence but the Opposite Parties have been hearing the written requests as well as telephonic and personal requests with deaf ears and therefore have not paid the total sum of mediclaim except a sum of Rs. 95,855/- out of the total claim of  Rs. 2,02,849/- being incurred in City Hospital and Rs. 1,08,356/- in Sir Ganga Ram Hospital, Delhi.  The Complainant has prayed for the Rs. 3,24,027/- in total including remaining claim amount with interest,  for mental harassment and for legal charges for notice.

Case of the Opposite Party No.1

2. The Opposite Party No.1 contested the case and filed written statement. The case of the Opposite Party No.1 is that the policy in question was obtained by the husband of the Complainant and the proposal form was signed by the husband of Complainant himself. The husband of the Complainant has concealed the true and correct information at the time of submitting the proposal form. The husband of the Complainant was patient of type II diabetes mellitus, diabetes retinopathy, hypertension, Acute on CKD and chronic kidney disease etc. The Opposite Party No.2 process the claim of the Complainant and found that claim of the Complainant falls under the exclusion clause no.4.3 of the policy terms and conditions etc. The policy which was purchased by the husband of the Complainant was Happy Family Floater Policy. The said policy clearly stipulates that “ During the period  of insurance cover, the expenses on treatment of following ailment/diseases/surgeries for the specific periods are not payable if, contracted and/or manifested during the currency of the policy” which are as under:

Sr. No.	Name of the Illness	Specific period for which illness is not covered
to
(xvii) Hypertension		Two years (02years)
(xviii) Diabetes		Two years( 02 years)
to

 

In Exclusion clause No.4.3 it is provided as under:

If the continuity of the renewal is not maintained wit the company then subsequent cover shall be treated as fresh policy and clauses 4.1, 4.2 and 4.3 will shall apply unless agreed by the company and suitable endorsement passed on the policy. Similarly, if the sum insured is enhanced subsequent to the inception of the policy, the exclusions4.1, 4.2 and 4.3 will apply aftresh for the enhanced portion of the sum insured for the purpose of this section.

In Exclusion clause No.4.3 it is provided as:

If these diseases are pre-existing at the time of proposal the exclusion no. 4.1 for pre-existing condition shall be applicable in such cases.

3. It is stated that the claim of the Complainant was found partly admissible and the same was allowed. The husband of the Complainant was type II Diabetes Mellitus and was also kidney patient so he was not covered under the exclusion clause which is referred above. It is prayed that the complaint may be dismissed. The Opposite Party No.2 did not contest the case despite service of the notice.

Rejoinder to the written statement of Opposite Party No.1

4. The Complainant filedrejoinder to the written statement of Opposite Party  No.1 wherein the Complainant has denied the pleas raised by the Opposite Party No.1 and has reiterated the assertion made in the complaint.

Evidence of the Complainants

5. The Complainant No.1 in support of her complaint filed her affidavit wherein she has supported the averments made in the complaint.

Evidence of the Opposite Party No.1

6. In order to prove its case, Opposite Party No.1 filed affidavit of Sh. Rajeev Chopra, Sr. Divisional Manager M/s Oriental Insurance Co. Ltd., Divisional Office-14 Patparganj Ind. Area Delhi, and one affidavit of Dr. Harish Nagpal, S/o Lt. Sh. Devender Pal Nagpal wherein the averments made in the written statement of Opposite Party No.1 have been supported.

 

Arguments & Conclusion

7. We have heard the Ld. Counsels for the parties. We have also perused the file and the written arguments filed by the parties.The case of the Complainant is that the husband of Complainant No.1 had purchased a health insurance policy from the Opposite Party No.1.The sum insured under the policy was  Rs. 3,00,000/-. Her case is that the husband of the Complainant No.1 was admitted for treatment in the hospitals. However her husband died. Thereafter the Complainant No.1 submitted the medical bills to the Opposite Party No.1 for reimbursement. Her case is that the claim was rejected without any valid reason.
8. On the other hand, the case of the Opposite Party No.1 is that the husband of the Complainant was patient of diabetes mellitus type II, retinopathy and kidney disease. Its case is that at the time of purchasing the policy the husband of the Complainant had submitted a proposal form and in the proposal form he has concealed the fact that he was suffering from the above mentioned diseases. Its case is that as the husband of the Complainant had concealed the fact that he was suffering from the above mentioned diseases and therefore the claim of the Complainant was rejected on the ground that the case falls under the exclusion clause which is referred above.
9. It is important to note that the Complainant in para 4 of her complaint has specifically mentioned that there was no objection on the part of the Opposite Party to not to pay the premium as the husband of the Complainant was a diabetic etc. The Complainant No.1 has also stated in para 4 of her complaint  that the husband of the Complainant No.1 was got medically examined by the penal doctor of the Opposite Party. It is further important to note that the Opposite Party No. 1 has filed written statement and there is a common reply of para no.2 to para no. 9 of the complaint and the perusal of the same shows that It is mentioned therein “ That the contents of para no.2 to 9 (along with its sub paras) of the complaint, insofar as matter of record, are not denied. However, anything contrary to the record is specifically denied. The Complainant be put to strict proof of the same”.
10.  It is clear that the Opposite Party No.1 has not specifically denied that the husband of the Complainant was not medical examined by its doctor. This is a vague denial made by the Opposite Party No.1 and has no value in the eyes of law. Therefore, it is to be presumed that the husband of the Complainant was got medically examined at the time of selling the policy to him.
11. Further, the case of the Opposite Party No.1 is that the husband of the Complainant has made a false declaration and has concealed the fact that the he was suffering from various diseases while submitting the proposal form. However the Opposite Party No.1 has not produced the said proposal form before the Commission nor any reason has been assigned as to why the proposal form has not been produced.
12. It is an admitted case that the Opposite Party No.1 has allowed and paid the claim of Rs. 95,855/- out of the total claim of Rs. 3,11,205/-. It is the case of the Opposite Party No.1 that the TPA had processed the claim of the Complainant and during scrutiny the same was found partly payable. It is a matter of ordinary prudence that if there was concealment of the diseases by the Complainant at the time of purchasing the policy then why the claim was partly allowed and partly rejected. No reason has been assigned as to why this was so done.
13. In view of the above discussion, we are of the opinion that the Opposite Party No.1 has failed to prove its defence and on the other hand the case of the Complainant supported with affidavit shows that there was deficiency of service on the part of Opposite Party No.1. Therefore, the complaint is allowed. Opposite Party No.1 is directed to pay the Complainants an amount of Rs. 2,15,350/- along with interest @ 9 % p.a. from the date of filing the complaint till recovery. The Opposite Party No.1 is further directed to pay to the Complainants an amount of Rs. 50,000/- toward mental harassment and litigation expenses with interest @ 9 % p.a. from the date of this order till recovery. Both the Complainants shall be entitled for the said compensation to equal shares.
14. Order announced on 29.11.24.

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

File be consigned to Record Room.

 

(Adarsh Nain)     Member

(Surinder Kumar Sharma) President