Delhi

North East

CC/19/2013

Smt. Usha Jain - Complainant(s)

Versus

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

07 Jul 2017

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM: N-E

GOVT. OF NCT OF DELHI

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

 

Complaint Case No. 19/2013

 

In the matter of:

 

	Smt. Usha Jain W/o Sh. P.K. Jain, R/o B-10/F-1, Dilshad Garden Delhi-110095.	Complainant
	Versus
	M/s  Oriental Insurance Company Ltd. Branch Office-9, Raj Block, Naveen Shahdara, Delhi-110032 Also At: A-25/27, Asaf Ali Road New Delhi-110002.	Opposite Party

 

	DATE OF INSTITUTION:	19-01-2013
	DATE OF DECISION      :	07-07-2017

 

Nishat Ahmad Alvi, Member:-

 

6698606.  

 

1. The facts of the case, in brief, are that complainant obtained a Mediclaim Policy Vide No. 271702/48/2013/128, from the OP, on 29.04.2009.  Prior to it she was having Mediclaim policy of National Insurance Company Ltd for the last about continuous 10 years. Just thereafter he got transferred the said policy with OP on 29.04.2009. Previous policy was got transferred to the OP in view of the circular vide No. HO/DGM(T)/91/2006/CR-6073 dated 14/09/2006  issued by OP. Clause No. 12 of this circular stipulates “On renewal of policies of other insurance companies where cumulative bonus is confirmed by the previous insurer, the insured will be given the benefit of continuity and pre-existing disease clause will be applied retrospectively for the period for which the cumulative bonus had been allowed”.
2. Complainant was hospitalized in Pushpanjali Crosslay Hospital between 18.06.2012 and 22.06.2012. Where she paid Rs. 1,00,000/- (Rupees one lac only) as expenses of the treatment. Claim for reimbursement of the same was lodged with OP who has repudiated the same vide its letter dated 9.8.12 stating that the complainant was having a pre-existing disease which is covered under exclusion clause no. 4.1 of the policy and that complainant is not registered with OP for last four years which is necessary for claiming under pre-existing disease. Vide letter dated 18.08.2012 complainant gave information regarding his claim and continuity benefits. Besides son of the complainant personally went to OP and  cleared all doubts. Despite that OP rejected her claim, thereafter, complainant also served a legal notice dated 29.11.2012 on OP but OP neither complied it nor replied.   Complainant has prayed for grant of directions to the OP to pay Rs. 1,00,000/- (Rupees one lac only) to reimburse the expenses incurred by the complainant and Rs. one Lac towards damages beside Rs. 11,000/- as litigation cost.
3. In the reply OP has submitted that the policy was taken from the OP company on 29.04.2009. At the time complainant lodged her claim the policy had completed three years and only fourth year was running. Policy issued for a period of one year w.e.f. 29.04.2012 to 28.4.2013. The patient aged about 65 years was hospitalized  w.e.f. 18.06.2012 to 22.06.2012 and admitted with a case of “Breathlessness of exertion and extreme weakness with nausea and vomiting. The complainant is also known case of “hypertension, hypothyroidism and dyslipidemia” vide discharge summary dated 23.01.2006 of Delhi Heart and Lungs Institute. However, the TPA M/s E-Meditek (TPA) Services Limited of the OP processed the claim of the complainant and found that the claim of the complainant falls in the 4^th year of policy inception, which comes under the exclusion clause no. 4.1 as well as clause no. 5.9 of policy terms and conditions of exclusion. Hence, after process of the claim of the complainant, the same was found inadmissible under condition no. 4.1 of the policy terms & conditions of individual Mediclaim Insurance Policy. Accordingly the claim of the complainant was rightly repudiated vide letter dated 09.08.2012 followed by other letter dated 10.09.2012, upon receiving the recommendations from the TPA.  Matter was re-opened on the request/ representation of the complainant and reviewed by the competent authority who also found the grounds, of repudiation, in accordance of the policy terms and conditions. Complainant was duly communicated about the status of claim in question vide letter dated 30/10/12. So far as circular relied on by the complainant is concerned, it is pleaded that the said circular was not for the general public at large and it was meant for internal guidelines for the insurance business of the company which was further clarified internally with respect to the continuity benefits, stating that continuity benefit can be given only if the policy is continued with Oriental Insurance itself.  OP has prayed for dismissal of the complaint as not maintainable.
4. Complainant has filed a rejoinder wherein he denying all the objections, being baseless, has inter alia pleaded that it was only because of the continuity benefit as allowed vide aforesaid circular that complainant took the policy in question from the OP. Otherwise there would have been no purpose for taking this policy from the OP.
5. Both the parties have filed their sworn affidavits and their respective written arguments.
6. Heard and perused the documents on record.
7. Undeniably, the complainant obtained Mediclaim Policy Vide No. 271702/48/2013/128 from the OP on 29.04.2009.  Prior to it she was holder of Mediclaim policy, from National Insurance Company Ltd., for the last about 10 years. Thereafter the complainant being entitled for no claim bonus transferred the said policy to the OP on 29.04.2009. Meaning thereby that during the course of period of about 10 years, the complainant did not lodge any medical claim with the National Insurance Co. Even otherwise it is not the case of the OP that the complainant had ever lodged any such medical claim with the National Insurance Co. and the same was paid to him.  Issuance of policy in question with no claim bonus by the OP itself proves that while issuing the policy in question the OP Company had already satisfied itself that the complainant had never made any medical claim with the National Insurance Company and that was the reason that the policy in question had been issued with no claim bonus.
8. Admittedly, complainant was hospitalized in Pushpanjali Crosslay Hospital w.e.f. 18.06.2012 to 22.06.2012 and paid Rs. 1,00,000/- towards medical expenses there. The claim was filed with the OP who repudiated the claim vide letter dated 10.09.2012 on the ground that the complainant was having    pre-existing disease  and hence his claim was barred under clause no. 4.1 and 5.9 of the policy terms and conditions.  As not denied by the OP circular no. HO/DGM(T)/ 191/2006/ CR-6073 containing Clause No. 12 reproduced  hereinabove is dated 14/9/2006.  Copy of email relied upon by the OP is Ex OP/2.  The same is dated 6/11/12.  The policy in question had been issued with no claim bonus by the OP on 29.04.2009.  Complainant got the treatment from Pushpanjali Crosslay hospital w.e.f. 18.06.2012 to 22.06.2012 and incurred Rs. 1,00,000/- on it .  The claim of the complainant was rejected on 10.09.2012 and further clarify on 30.09.2012. Till that time the alleged circular / email was having no existence and it was issued only on 6.11.2012 about a month thereafter. Therefore, we find no reason or bonafide in the contention of the OP to rely on such non- existent communication / email that too only internally among OPs itself. It is beyond our comprehension and imagination as to why before taking such frivolous, imaginary and ridiculous plea in this forum the officers of the OP would not have thought over the matter throughly. Rather they would have avoided to take such irresponsible and childish baseless plea before us.
9. Thus in our view complainant has very successfully established that the policy in question was issued by OP on the basis of no claim bonus giving continuity benefits as per circular No. HO/DGM(T)/91/2006/CR-6073 dated 14/09/2006.  Clauses 4.1, which deal with rejection of medical claim during the first four years of the policy on the basis of pre existing disease and 5.9, which deals with fraud/misrepresentation/ concealment of facts of the policy as claimed by the OP, do not apply in the facts and circumstances of the present case.
10.  In view of the above discussion, we hold OP guilty for, adopting unfair trade practice and committing gross deficiency in service. 
11. Therefore, allowing the complaint we direct the OP to

1. reimburse Rs. 1,00,000/- (Rupees one lac only), to the complainant, alongwith interest thereon @9% p.a. w.e.f. 10.09.2012 – the date claim was repudiated on, till final compliance of this order; and 
2. Pay Rs. 20,000/- (Rupees Twenty Thousand only) as compensation; and
3. Litigation cost of Rs. 11,000/- (Rupees Eleven Thousand only)

12. Order shall be complied within 30 days from the date of receipt hereof, by the OP.

Failing which interest on Rs. 1,00,000/- (Rupees one lac only) shall be charged at increased rate of 12% p.a.

13. Let copy of this order be sent to each party, free of cost, as per Regulation 21 of the Consumer Protection Regulations 2005.
14. File be consigned to record room.
15. Announced on: - 07.07.2017

 

(N.K. Sharma) President

(Nishat Ahmad Alvi) Member