District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.218/2019.
Date of Institution: 01.05.2019.
Date of Order: 13.07.2022.
Abhishek Gupta son of Shri Kalicharan Gupta resident of H.No. 144, Ward No.8, Baniawara, Ballabgarh, District Faridabad.
…….Complainant……..
Versus
1. The Oriental Insurance Company Limited, Registered office: Oriental House, P.B.No 7037, 1-25/27, Asaf Ali road, New Delhi – 110 002 through its Manager,.
2nd Address: Divisional Office: 4 B.P., 1st floor, Neelam Bata Road, NIT, Faridabad – 121001 through its Divisional Manager.
2. Park Mediclaim TPA Pvt. Ltd., 702, Vikrant Tower, Rajendera Place, New Delhi – 110 008.
…Opposite parties……
Complaint under section-12 of Consumer Protection Act, 1986
Now amended Section 34 of Consumer protection Act 2019.
BEFORE: Amit Arora……………..President
Mukesh Sharma…………Member.
PRESENT: Sh. Yogesh Attri, counsel for the complainant.
Sh. Joginder Singh, counsel for opposite party No.1.
Opposite party No.2 ex-parte vide order dated 17.01.2020.
ORDER:
The facts in brief of the complaint are that the complainant was the insured from the opposite party vide policy No. 272400/48/2014/8427 dated 21.11.2013 to 20.11.2014 for the risk cover amount of Rs.3,00,000/-. On 27.06.2014, the father of the complainant namely Kalicharan was admitted in Metro heart Institute, Sector-16A, Faridabad with the complaint of chest pain left side and remained in hospital till 29.06.2014 as earlier during the course of treatment, the Echo & Coronary Angiography was done and after the Echo & Coronary Angiography, primary PTCA with Eluting stenting to LAD but again on 27.06.2014, the father of the complainant feel pain in the left side of his chest and coronary angiography & primary PTCA to LAD done by the doctors of Metro heart Institute. The father of the complainant was discharged on 29.06.2014. At the time of admission in the hospital, the necessary intimation was given to the opposite parties. The complainant filed the claim before the opposite parties vide claim No. 01CDR2/12673 for claiming the amount of Rs.1,25,950/-. The opposite parties declined the claim of the complainant giving the reason “It was observed that previously when patient was hospitalized from 04.03.2013 to 07.03.2013 for CAD had already been denied by the Vipul Medicorp TPA, which was exclusion for the first two year of policy and reputation under the clause No. 4.3.” Upon issuing the letter issued by opposite party No.2, the complainant filed the request to reconsider the same and also produced the certificate on dated 11.04.2014 again on 22.03.2017. The claim of the complainant was not repudiation under the clause No.4.3 and cover just after insured with opposite party No.1 as the patient was admitted with the complaint of chest pain left side ghabrahat only and no past history of HTN was at the time of admission in metro heart institute dated 04.03.2013. In the said certificate Dr. Neeraj Jain specially mentioned that there
was no past history of HTN in the past vide letter dated 30.03.2013. Ultimately the complainant had made many requests to the officials of the opposite parties after visiting personal but they refused to admit the claim of the complainant. 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) give Rs.1,25,950/- with interest @ 18% p.a. from the date of 29.06.2014..
b) pay Rs.1,00,000/- as compensation for causing mental agony and harassment .
c) pay Rs.11,000/ - as litigation expenses .
2. Opposite party No.1 put in appearance through counsel and filed written statement wherein Opposite party No.1 refuted claim of the complainant and submitted that the present complaint was not legally maintainable against the answering opposite party in any manner whatsoever as the complainant had failed to pin point any deficient or short services rendered by the answering opposite party while rendering insurance services to the complainant in respect of Happy Family floater Insurance Policy No. 272400/48/2014/8427 covering the insurance risk from 21.11.2013 to 20.11.2014 issued in the name of Abhishek Gupta whereby all the dependent family members were got insured including Shri Kalicharan Gupta. The complainant had concealed the fact that the complainant was suffering from hypertension for the last several years, which fact would become clear from the prescription dated 04.03.2013 of Bhavya Kalayani Hospital, Ballabgarh, whereby the BP of Shri Kalicharan Gupta was noted as 190.110. The father of the complainant Kalicharan Gupta was also taken to Agarsen Hospital, Kithwari Chowk, Delhi Mathura Road, Palwal, where his BP was recorded as 130/90 in his OPD card dated 27.06.2014. The father of the complainant Kalicharan Gupta was taken to Metro Heart Institute, Sector-16A, Faridabad on
27.06.2014 where the attending doctor recorded that the patient Kalicharan Gupta was having history of hypertension (Not on Regular Medication). It was submitted that under the above mentioned Happy Family Floater Policy, the insured Kalicharan was not entitled for expenses incurred on his treatment under Clause 4.3 of the insurance policy. As per the available record of the insurer opposite party No.1, Shri Kalicharan Gupta was got admitted in Metro heart Institute, sEctor-16A, Faridabad on 27.06.2014 as a case of Pst PTCA with Stenting to MID LAD (2013), late Stent Thrombosis, CAD (Coronary Artery Disease), Primary PTCA to LAD, LVDysfunction and Apical LV clot, whereby Coronary Angiography and Primary PTCA to LAD was done on 27.06.2014 and was discharge don 29.06.2014. The complainant alleged that an amount of Rs.1,25,950/- was spent on the treatment of Shri Kalicharan Gupta but no such hospitalization bill was ever submitted to the answering opposite party at any point of time. However, the complainant submitted claim form claiming Rs.1,25,950/- on 11.07.2014. The complainant was required to submit all the required claim documents within 7 days from the discharge of the hospital and as such M/s. Park Mediclaim TPA Pvt. Ltd., the opposite party No.2, the third party administrator of opposite party No.1 sent final reminder-cum-closure letter dated 10.09.2014 calling upon the complainant to submit all the documents/information within 15 days of the receipt of the letter to ensure speedy services falling which it shall be presumed that the complainant was not more interested to pursue the claim as such the file would be closed as “NO claim”. Since the complainant failed to complied the letter, the mediclaim of the complainant was denied invoking the Exclusion Clause 4.3 of the Happy Family floater Insurance Policy, as the insurance policy No. 272400/48/2014/8427 covering the insurance risk from 21.11.2013 to 20.11.2014 was 2nd year policy. The present complaint was not legally
maintainable as the present complaint was hopelessly time barred by period of limitation. It was worth mentioning that as per the Consumer Protection aCt the complaint can be filed only within a period of two years from the date of taking the insurance policy and or from the date of repudiation of claim, whereas, the complainant had filed the present complaint in the year 2019, highly belately as such the present complaint requires outright dismissal on this short ground only.Opposite party No.1 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. Notice issued to opposite party No.2 received back served alongwith tracking details. Case called several times since morning but none appeared on behalf of opposite party No.2 Therefore, opposite party No2 was hereby proceeded against exparte vide order dated 17.01.2020.
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 – Oriental Insurance Co. Ltd. with the prayer to : a) give Rs.1,25,950/- with interest @ 18% p.a. from the date of 29.06.2014.. b) pay Rs.1,00,000/- as compensation for causing mental agony and harassment . c) pay Rs.11,000/ - as litigation expenses .
To establish his case the complainant has led in his evidence Ex.CW1/A – affidavit of Abhishek Gupta,, Ex.C-1 – email dated 11.09.2018,, Ex.C2 – order dated 17.11.2017,, Ex.C-3 – claim form,, Ex.C-4 – discharge summary,, Ex.C-5 – Happy Family Floater Policy Schedule, Ex.C-6 – letter dated
22.03.2017, Ex.C-7 – letter dated 09.12.2015, Ex.C-8 – letter dated 17.04.2013.
On the other hand counsel for the opposite party No.1 strongly agitated and opposed. As per the evidence of the opposite party No.1 , Ex.RW1/A – affidavit of Shri Ramesh, Senior Divisional Manager M/s. Oriental Insurance company Limited, Faridabad, Ex.R-1/1 – Happy Family floater Insurance Policy, Ex.R-1/2 - Terms and conditions, Ex.R-1/3 – prescription slip,, Ex.R-1/4 – OPD card,, Ex.R-1/5 – Discharge summary, Ex.R-1/6 – Relevant Investigations reports,, 7Ex.R-1/7 (colly) – tests,, Ex.R-1/8 – claim form Ex,R-1/9 – letter dated 09.12.2015.
7. In this case the complainant was the insured from the opposite party bearing policy No. 272400/48/2014/8427 dated 21.11.2013 to 20.11.2014 for the risk cover amount of Rs.3,00,000/-. On 27.06.2014, the father of the complainant namely Kalicharan was admitted in Metro heart Institute, Sector-16A, Faridabad with the complaint of chest pain left side and remained in hospital till 29.06.2014 as earlier during the course of treatment, the Echo & Coronary Angiography was done and after the Echo & Coronary Angiography, primary PTCA with Eluting stenting to LAD but again on 27.06.2014, the father of the complainant feel pain in the left side of his chest and coronary angiography & primary PTCA to LAD done by the doctors of Metro heart Institute. The father of the complainant was discharged on 29.06.2014. At the time of admission in the hospital, the necessary intimation was given to the opposite parties. The complainant filed the claim before the opposite parties vide claim No. 01CDR2/12673 for claiming the amount of Rs.1,25,950/-. It is evident from letter dated 10.09.2014 regarding final reminder cum closure letter in which it has been mentioned that “all the policy copies confirming coverage of the patient under mediclaim policy prior to 21.11.2013. The reason for delay in submission of claim documents after 7 days of discharge from the hospital. Please submit documents/information to us within 15
days from the date of this letter at our office address to ensure speedy services otherwise we shall presume that your no more interested to pursue the claim any further and would close the file as “No Claim.” As per letter dated 09.12.2015 vide Ex.C-7 written by the opposite party to the complainant in which it has been mentioned that “your claim is not tenable on the following grounds:
On scrutiny of the claim papers it is observed that you have not replied to our TPA’s querry letters alongwith final reminder & closure letter on 10.09.2014. As such, we presumed that you are not interested your claim. Therefore, your claim is closed as NO Claim.”
8. As per Ex.C6, letter written by the complainant to Divisional Manager, Oriental Insurance Company Limited, Faridabad regarding re-open the file which was received by the opposite party No.2 on 22.03.2017.
9. After going through the evidence led by the parties, the Commission is of the opinion that As per dictum of Section 24-A of Consumer Protection Act 1986, the District Commission is empowered to admit a complaint within two years from the date on which the cause of action has arisen. It is evident from Ex.C-7 in which it has been mentioned that your claim is not tenable on the following grounds:
On scrutiny of the claim papers it is observed that you have not replied to our TPA’s querry letters alongwith final reminder & closure letter on 10.09.2014. As such, we presumed that you are not interested your claim. Therefore, your claim is closed as NO Claim.” The present complaint is time barred under Limitation Act as the opposite party had already closed the subject claim vide closure letter dated 10.09.2014 and the present complaint has been instituted in the year 2019.
10. Resultantly, the complaint is dismissed being time barred. Copy of this order be given to the parties free of costs and file be consigned to the record room.
Announced on: 13.07.2022 (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
