Delhi

North

CC/54/2018

SUNIL GUPTA - Complainant(s)

Versus

M/S. NATIONAL INSURANCE CO. LTD. - Opp.Party(s)

ASHIMA TAYAL

31 Jul 2023

ORDER

    District Consumer Disputes Redressal Commission-I (North)                  

[Govt. of NCT of Delhi]

Ground Floor, Court Annexe -2 Building, Tis Hazari Court Complex, Delhi- 110054

 

Consumer Complaint No.: 54/2018

 

Sh. Sunil Gupta,

S/o Sh. Shiv Narain Gupta,

2550, Sadak Prem Narain,

Churi Walan, Delhi-110006.                      ….                        Complainant

                                                                               

                                                                                Vs

 

M/s National Insurance Co. Ltd.

(Office code 354501),

30-31 A, Jeevan Vikas Building,

2^nd Floor, Asaf Ali Road,

New Delhi-110002.                                         ....              Opposite Party  

 

ORDER

          31/07/2023

 

Ashwani Kumar Mehta, Member:

 

(1)          The present complaint has been filed under Section 12 of the Consumer Protection Act, 1986. The brief details of facts, as alleged by the Complainant in the Complaint in hand, are that the Complainant is insured with OP vide Mediclaim Family Policy No.35401501710000381  valid from 28.06.2017 to midnight of 27.06.2018. The minor son of the complainant, Gaurav, aged about 17 years, is also covered under the above referred policy alongwith the Complainant for a sum of Rs.1,90,000/- including bonus. M/s E-Meditek Insurance TPA Ltd. has been nominated as TPA by the OP to settle all claims under the above policy. The Complainant has initially taken this policy for himself, his wife, his minor son and minor daughter from the OP on 28.06.2005. The said Mediclaim policy of the family was continuously being renewed on year to year basis and was valid till 27.06.2018. It is further stated that Gaurav son of the Complainant, was covered under the said Mediclaim policy since inception in the year 2005 and no claim has been taken from OP insurance company during the last 13 years upto 27.06.2017 for him. The Complainant’s son Gaurav was admitted in Vimhans Hospital on 21.08.2017 and remained admitted upto 08.09.2017 for which cashless claim was denied. It is alleged that the Complainant incurred a sum of Rs.1,30,548/- for treatment of his son and submitted claim of this amount to TPA E-Meditek vide claim No.122081704502 but the TPA E-Meditek has denied this claim vide letter dated 11.10.2017, received on  06.11.2017, under exclusion clause 4.1 Psychiatric disorder. Thereafter, the Complainant wrote to the OP and TPA on 14.11.2017 stating that the claim has been rejected wrongly and illegally because the exclusion clause 4.1 was not applicable in year 2005 when this policy was initially taken by the Complainant. The letter dated 14.11.2017 of the Complainant remained unattended as neither any reply was received nor the amount was reimbursed by the OP to the Complainant.

 

2.           The Complainant has further alleged that the claim has been wrongly and illegally rejected because the 4.1 Exclusion clause was not applicable in the year 2005 when the policy was initially taken by the complainant and was not a part and parcel of the Mediclaim policy issued by the Opposite Party. This cannot be termed as a pre-existing disease and does not cover the exclusions as termed in 4.1 clause. The Policy issued by the OP in the year 2005 reads as under:-

 

“This insurance shall not extend to pay any expenses incurred relating to the disease/sickness/injury mentioned in this column & for consequences attributable thereto or accelerated thereby or arising therefrom.”

 

It has also been stated that clause 4.1 referred to by the OP is as under:-

 

“4-Exclusions:-  “The company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any person in connection with or in respect of:

4.1 All diseases/ injury which are pre-existing when the cover incepts for the first time. However, those diseases will be covered after four continuous claim free policy years. For the purpose of applying this condition, the period of cover under Mediclaim policy taken from National Insurance Company only will be considered. This exclusion will also apply to any complications arising from pre-existing ailment/ disease/ injuries. Such complications will be considered as a part of the pre-existing health condition or disease.

 

3.            The Complainant has also alleged that none of the condition of exclusion clause 4.1, relied upon by the OP, is applicable in his case and the OP has made deficiency in service by disallowing the claim of the Complainant amounting to Rs.1,30,548/- which is genuine and has been actually incurred by the  Complainant and the OP is liable to reimburse to the Complainant alongwith compensatory costs, interest and litigation expenses. The Complainant has prayed to:-

 

1.            Pass an order directing the OP to pay to the Complainant a sum of Rs.1,30,548/-, the claim of payment of which has been denied by the OP.

2.           Pass an order thereby directing the OP to pay to the Complainant a sum of Rs.10,000/- as compensatory damages for the mental agony caused to the Complainant.

3.            Pass an order for granting interest @ 18% P.A. or any other rate this Hon’ble Forum deems fit an proper upon the defaulted amount from the date of payment or from any other date or from the date of filing of the present complaint till its realization.

4.           Pass an order thereby awarding costs to the tune of Rs.10,000/- of the present litigation in favour of the Complainant.

 

4.           The Complainant has also filed a copy of judgment passed by the Hon’ble High Court of Delhi on 26.02.2018 in the matter of Ms. United India Insurance Company Vs. Jai Prakash Tayal in support of his claim.

 

5.            Accordingly, notice was issued to the OP and in response, the OP has filed its reply stating that the present complaint is liable to be dismissed as no deficiency of service as contemplated under Section 2 (1) (g) of the Consumer Protection Act, 1986 has been made out against the OP Company. It has further been stated that the claim in question was rightly denied by TPA as same falls under the exclusion clause 4.1 and 4.10 of mediclaim policy. Psychiatric Disorder, Intentional self-inflicted injury, attempted suicide are not covered under the Hospitalisation benefit policy issued. However, the TPA M/s E.Meditek (who has not been impleaded as necessary party) processed the claim in goodwill gesture of the OP Company but the patient miserably failed to fulfil the claim formalities, thus, the claim of the Complainant was closed due to non-compliance of the “above queries” as raised by the TPA. Moreover, the complainant instead to fulfil his part of obligation insisted the process of his claim without submitting any requisite documents. The TPA observations were correct as per terms and conditions of the policy issued. Hence, it comes under the exclusion clause 4.1 and 4.10 of the policy terms, conditions and exclusions of “Hospitalisation benefit policy”.

 

6.           It is further stated by OP that the amount claimed as compensation is highly exorbitant, exaggerated, irrational, unjust and not based on the facts and well-guided computation, hence, the answering OP is as such not liable to pay any cost and compensation to the complainant.

               

7.            Accordingly, the complaint has been examined in view of the facts of the case and averments/documents/Evidence put forth by the complainant & OP and it has been observed that:-

 

1. The OP has stated that the amount claimed as compensation is highly exorbitant, exaggerated, irrational, unjust and not based on the facts and well-guided computation but it has failed to justify its contention as to how the amount claimed as compensation is highly exorbitant, exaggerated, irrational and unjust?

 

2. The OP has communicated the repudiation of the claim to the complainant vide repudiation letter dated 11.10.2017  as per following wordings:-

 

“We are in receipt of the claim form & associated documents of GAURAV. On scrutiny of the same, we observe that he/ she was admitted in Vimhans Hospital.Claim recommended for rejection under exclusions 4.10 as Psychiatric disorder, Treatment for- psychiatric and psychosomatic disorders/diseases, is not payable as per policy T&C. 17 years old child admitted for c/o learning disorder, 1 mnth history of withdrawal behavior, low mood, decreased talk diagnosed as tripolar effective disorder, current episode manic with psychotic symptom, on medical management.

In this regard, we wish to inform you that the Claim is not payable as per-1) 4 EXCLUSIONS:- The company shall not be liable to make any payment under the policy in respect of any expenses incurred in connection with or inrespect of: 4.10 Psychiatric disorder, intentional self-inflicted injury-treatment for all psychiatric and psychosomatic disorders/diseases, intentional self-inflicted injury, attempted suicide.

In view of the above, we regret to inform you that, as per the instructions of National Insurance Co. Ltd., the claim is being denied on account of the above mentioned terms of the policy. For any further clarifications you may directly contact the insurer.”

 

On the other hand, the OP in its reply to the complaint, at para 6 of preliminary objections, has stated that the TPA- M/s E.Meditek (who has not been impleaded as necessary party) processed the claim in goodwill gesture of the OP Company but the complainant miserably failed to fulfil the claim formalities, thus, the claim of the Complainant was closed due to non-compliance of the “above queries” as raised by the TPA. Moreover, the complainant instead to fulfil his part of obligation insisted the process of his claim without submitting any requisite documents. But the OP has not mentioned as to which formalities were not completed by the complainant for which the claim was closed by the TPA? Moreover, no details of queries are not mentioned in the reply which have been referred as “above queries”. The OP has also failed to place any documents on records to prove its contention.

 

Besides, the above version of the OP for closure/repudiation of the complainant’s claim, is different from the contents of the repudiation letter dated 11-10-2017.

 

In view of the above position, the judgment passed by the Hon’ble Supreme Court in the matter of Saurashtra Chemicals Ltd. Vs. National Insurance Co. Ltd. [(2019) 19 SCC 70] appears relevant in this case wherein it has been held that the Insurance Company cannot travel beyond the grounds mentioned in the letter of repudiation.

 

3. The Complainant has pointed out in the complaint at Para 17 and 18 that such exclusion clauses were not applicable in the year 2005 when the policy was taken by the Complainant initially and this policy is continuously being renewed by the Complainant. The OP has not denied this fact in its reply filed to the allegations/complaint and has simply replied with a common statement for Para 11 to 19 that “this is a matter of record and the Complainant be put to strict proof of the same.”

 

4. It is not disputed that the Complainant bought his first policy from the OP in the year 2005 which is being renewed continuously and the OP has failed to prove that the exclusion clauses, relied upon by OP to repudiate the claim, were also applicable in the year 2005 when the policy was bought initially by the complainant.

 

5. Further, it is also settled proposition that once an insurance policy has been issued, the conditions of the same cannot be altered. Renewal of an insurance policy means repetition of the original policy. The judgment passed by the Hon’ble Supreme Court in the matter of Biman Krishna Bose Vs. United India Insurance Ltd.  2001(6) SCC 477 is also relevant wherein it has been held that:-

“A renewal of an insurance policy means repetition of the original policy. When renewed, the policy is extended and the renewed policy in the identical terms from a different date of its expiration comes into force. In common parlance, by renewal, the old policy is revived and it is sort of a substitution of obligations under the old policy unless such policy provides otherwise. It may be that on renewal, a new contract comes into being, but the said contract is on the same terms and conditions as that of the original policy.”

 

8.           In view of the above observations, we are of the considered view that the repudiation of the claim by the OP is unjustified which amounts to deficiency in service and the Complainant has suffered directly due to deficiency in service on the part of the OP (M/s National Insurance Co. Ltd.) in terms of the deficiency defined in the Act which includes any fault, imperfection, shortcoming or inadequacy in the quality, nature and manner of performance which is required to be maintained in relation to any service and includes any act of negligence or omission or commission by such person which causes loss or injury to the consumer.

               

9.           Therefore, we feel appropriate to direct the OP (M/s National Insurance Co. Ltd.) to pay Rs.1,30,548/- (Rupees One Lakh Thirty Thousand Five Hundred and Forty Eight Only) within thirty (30) days from the date of this order, with interest at the rate of 9% p.a. from 11.10.2017 (date of repudiation of the claim) till the date of the payment. Besides, the OP is also directed to pay Rs. 25,000/- (Rupees Twenty Five Thousand only) as compensation to the Complainant for the mental pain, agony and harassment. It is clarified that if the abovesaid amount is not paid by the OP to the Complainant within the period as directed above, the OP shall be liable to pay interest @12% per annum from the date of expiry of 30 days period.

 

10.         Order be given dasti to the parties in accordance with rules. Order be also uploaded on the website. Thereafter, file be consigned to the record room.

 

 

 

ASHWANI KUMAR MEHTA                          DIVYA JYOTI JAIPURIAR

               Member                                                          President

      DCDRC-1 (North)                                                  DCDRC-1 (North)