District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.53/2021.
Date of Institution: 02.02.2021.
Date of Order: 29.09.2022.
Raj Pal S/o Late Shri Bhima R/o House No. 491, Near Mobile Tower Road, Vilalge Chandawali, P.O.Ballabgarh, tehsil Ballabgarh, District Faridabad – 121004 (Hr.).
…….Complainant……..
Versus
1. M/s. Universal Sompo General Insurance Company Ltd., Regd. Office:- Unit NO. 401, 4th floor, Sangam Complex, 127, Andheri, Kurla Road, Andheri (East) Mumbai – 400 059.
2. The Branch Manager, M/s. Universal Sompo General Insurance Company Ltd., Unit No. 903-904, 9th floor, GDITL Tower, Netaji Subhash Place, Pitampura, New Delhi – 110 034.
3. M/s. Universal Sompo General Insurance Company Ltd., Assotech One, 5th floor, Plot NO. C-20/1A, C-Block, Sector-62, Noida – 201309 (U.P)
4. The Branch Manager, M/s. Universal Sompo General Insurance Company ltd., Ist Floor, SCF-2, Ashoka Enclave-1, sEctor-35, Faridabad – 121003(Hr.)
…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.
Indira Bhadana…………Member.
PRESENT: Sh. Sandeep Narwat and Shri Amit Sharma, counsel for the complainant.
Sh. Nitish Kumar, counsel for opposite parties.
ORDER:
The facts in brief of the complaint are that the complainant had obtained the Complete Healthcare Insurance Policy form opposite party No.2 under the administrative control of opposite party No.1 against the consideration paid in the form of insurance premium in the joint name of the complainant and his wife Smt. Sukhwat. The list of insurance policies purchased and obtained from the opposite parties was as under:
- The Complete Healthcare Insurance Policy No. 2825/56532178/00/000 for the period 13.09.2016 to 12.09.2017 covering the risks in the name of Raj Pal and Smt. Sukhwati for basic sum insured of Rs.6,00,000/- (Family Floater Basis).
- The Complete Healthcare Insurance Policy NO. 2825/56532178/01/000 for the period 13.09.2017 to 12.09.2018 covering the risks in the name of Raj Pal and Smt. Sukhwati for basic sum insured Rs.6,00,000/- (Family Floater Basis).
- The Complete Healthcare Insurance Policy No 2825/56532178/02/000 for the period 13.09.2018 to 12.09.2019 covering the risks in the name of Raj Pal and Smt. Sukhwati for Basic sum insured Rs.6,00,000/- (Family Floater Basis).
- The Complete Healthcare Insurance Policy No. 2825/56532178/03/000 for the period 13.09.2019 to 12.09.2020 covering the risks in the name of Raj pal and Smt. Sukhwati for basic sum insured Rs.6,00,000/- (Family Floater Basis).
The insured – Smt. Sukhwati suddenly felt pain in lower back and attended the Asian Institute of Medical Sciences, Badkhal – Flyover Road, Sector-21A, Faridabad on 27.07.2020. As a result, the patient – Smt. Sukhwati was admitted with complaint of pain in lower back and right leg, unable to bear weight. Accordingly, the patient remained admitted in the said hospital for 27.07.202 to 02.08.2020 diagnosed as a case of Recurrent PIVD, L-4, L-5 with Right Lower Limb Radiculopathy for which the surgery was conducted by the doctor and thereafter discharged on 02.08.2020 with advise of follow up. The complainant was entitled “Cashless Hospitalization” under the complete Healthcare Insurance Policy No. 2825/56532178/03/000 for the period 13.09.2019 to 12.09.2020 so the hospital sent a cashless request to the opposite party No.3. Since the opposite party No. 3 was functioning under the administrative control as well as a co-ordinator branch for and on behalf of opposite parties Nos.1,2 & 4 dealing with mediclaim hospitalization of the insured person. But to the utter surprise to the complainant, such cashless request was declined by the opposite parties. As a result, the hospital raised a final bill dated 02.08.2020 to the tune of Rs.2,93,291/- which was accordingly paid by the complainant from his own pocket. Thereafter the complainant lodged a regular claim alongwith the original medical treatment record with the opposite party No.3. But the opposite party NO.3 being co-ordinator branch for and on behalf of opposite parties Nos.1,2 & 4 rejected the said mediclaim vide letter of repudiation dated 27.09.2020 alleging reasons that the patient underwent surgery intervention for same ailment 20 years back falling prior
to policy inception. It was submitted that the letter of repudiation dated 27.09.2020 on the face of it, was inconsistent and contrary inter-alia by taking the shelter under the alleged terms and conditions of the insurance policy. The complainant hereby refuted and deny all the reasons grounds and the allegations leveled in the letter of repudiation dated 27.09.2020 in rejecting the legitimate valid and payable claim of the complainant. Opposite parties had already admitted and released a mediclaim in respect of hospitalization of the insured – Smt Sukhwati hospitalized for the period 08.02.2018 to 12.02.2018 under the complete Healthcare Insurance Policy No. 2825/56532178/01/000 for the period 13.09.2017 to 12.09.2018, thus, abandoning the applicability of any exclusion clause contained in the medi insurance policy, if any, though not admitted. The complainant sent legal notice dated 06.11.2020 to the opposite party but all in vain. The aforesaid act of opposite parties amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite parties to:
a) make the payment of principal claim amount Rs.2,93,291/- againsat bill dated 02.08.2020 plus subsequent follow up medical expenses alongwith interest @ 18% p.a. form the dte of payment to the hospital till its realization as a whole.
b) pay Rs. 1,00,000/- as compensation for causing mental agony and harassment .
c) Any such relief which this Hon’ble Court may deem proper in the circumstance of the case may kindly be awarded in favour of the complainant and against the opposite parties.
2. Opposite parties put in appearance through counsel and filed written statement wherein Opposite parties refuted claim of the complainant and submitted that opposite party No.1 had rightly refused the claim of the complainant as the
complainant had misrepresented the opposite party No.1 while taking the insurance policy as the complainant’s wife had already undergone a surgery for the same issue 20 years ago and had not mentioned about the same during the process of obtaining the insurance policy which violates the terms and condition of the insurance policy. Opposite parties denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. The parties led evidence in support of their respective versions.
4. We have heard learned counsel for the parties and have gone through the record on the file.
5. In this case the complaint was filed by the complainant against opposite parties– Universal Sompo General Insurance with the prayer to: a) make the payment of principal claim amount Rs.2,93,291/- against bill dated 02.08.2020 plus subsequent follow up medical expenses alongwith interest @ 18% p.a. form the dte of payment to the hospital till its realization as a whole. b) pay Rs. 1,00,000/- as compensation for causing mental agony and harassment . c) Any such relief which this Hon’ble Court may deem proper in the circumstance of the case may kindly be awarded in favour of the complainant and against the opposite parties.
To establish his case the complainant has led in his evidence, Ex.C-1 – insurance policy valid from 13.09.2020 to 12.09.2021,, Ex.C-2 – insurance policy valid from13.09.2019 to 12.09.2020, Ex.C-3 – insurance policy valid form 13.09.2018 to 12.09.2019, Ex.C-4 – insurance policy valid from 13.09.2017 to 12.09.2018, Ex.C-5 – insurance policy valid form 13.09.2016 to 12.09.2017, Ex.C-6 – Claim repudiation letter, Ex.C-7 – letter dated 28.07.2020,, Ex.C-8 – Discharge summary, Ex.C-9 – casualty card,, Ex.C-10 – Final Bill summary,, Ex.C-11 to 14 – Deposit Receipts, Ex.C-15 – GDT Invoice,, Ex.C-16 – OPD slip dated 04.08.2020,, Ex.C-17 to 21 – Bill cum receipts, Ex.C-22 – GST Invoice, Ex.C-23 – Discharge summary, Ex.C-24 – legal notice, Ex.C-25 to 28 – postal receipts,, Ex.C-29 – Aadhar card.
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 Prashant V. Shukla S/o Shri Vinod Shukla , office at Mumbai.
6. In this case. the complainant had obtained the Complete Healthcare Insurance Policy form opposite party No.2 under the administrative control of opposite party No.1 against the consideration paid in the form of insurance premium in the joint name of the complainant and his wife Smt. Sukhwat. The list of insurance policies purchased and obtained from the opposite parties was as under:
- The Complete Healthcare Insurance Policy No. 2825/56532178/00/000 for the period 13.09.2016 to 12.09.2017 covering the risks in the name of Raj Pal and Smt. Sukhwati for basic sum insured of Rs.6,00,000/- (Family Floater Basis).
- The Complete Healthcare Insurance Policy NO. 2825/56532178/01/000 for the period 13.09.2017 to 12.09.2018 covering the risks in the name of Raj Pal and Smt. Sukhwati for basic sum insured Rs.6,00,000/- (Family Floater Basis).
- The Complete Healthcare Insurance Policy No 2825/56532178/02/000 for the period 13.09.2018 to 12.09.2019 covering the risks in the name of Raj Pal and Smt. Sukhwati for Basic sum insured Rs.6,00,000/- (Family Floater Basis).
- The Complete Healthcare Insurance Policy No. 2825/56532178/03/000 for the period 13.09.2019 to 12.09.2020 covering the risks in the name of Raj pal and Smt. Sukhwati for basic sum insured Rs.6,00,000/- (Family Floater Basis).
The insured – Smt. Sukhwati suddenly felt pain in lower back and attended the Asian Institute of Medical Sciences, Badkhal – Flyover Road, Sector-21A, Faridabad on 27.07.2020. As a result, the patient – Smt. Sukhwati was admitted with complaint of pain in lower back and right leg, unable to bear weight. Accordingly, the patient remained admitted in the said hospital for 27.07.2020 to 02.08.2020 diagnosed as a case of Recurrent PIVD, L-4, L-5 with Right Lower Limb Radiculopathy for which the surgery was conducted by the doctor and thereafter discharged on 02.08.2020 with advise of follow up. Opposite parties repudiated the claim of the complainant vide letter dated 27.09.2020 vide Ex.C-6 on the ground that Ms. Sukwati 55 years female covered under CHI Healthcare Policy. Patient admitted in AIIMS Hospital with complaints of pain in lower back and right leg. Unable to bear weight, prickling sensation in right leg. Patient diagnosed with PIVD underwent L4 Laminectomy and Dissectomy with fixation. On further scrutiny of documents it is found that insured had underwent surgical intervention for same ailment 20 years back, which falls to policy inception and is a major non disclosure. In this regard, the claim was not admissible as per following policy clause:
“As per CHI Healthcare Policy: Disclosure to information norm means the policy shall be void and all premium paid hereon shall be forfeited to the company, in the event of misrepresentation, mis-description or non-disclosure of any material fact.
7. After going through the evidence led by the parties, the Commission is of the opinion that when the insured age is 01.01.1964 then the Insurance Company was at liberty to get the complainant medically examined prior to issuance of the policy in question. Insurance Company cannot take advantage of its act of omission and commission as it is under obligation to ensure before issuing the policy in question whether a person is fit to be insured or not. It was the duty of the opposite party to get the complainant immediately examined before issuing the policy as per IRDA guidelines. Hence,the complaint is allowed. Opposite parties are directed to process the claim of the complainant within 30 days of receipt of the copy of order and pay the due amount to the complainant along with interest @ 6% p.a. from the date of filing of complaint till its realization. The opposite parties are also directed to pay Rs.2200/- as compensation on account of mental tension, agony and harassment alongwith Rs.2200/- as litigation expenses to the complainant. Copy of this order be given to the parties concerned free of costs and file be consigned to record room.
Announced on: 29.09.2022 (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.
