Delhi

New Delhi

CC/253/2013

Jitender Sharma - Complainant(s)

Versus

M/S. Royal Sundaram Alliance Insurance Company Ltd. - Opp.Party(s)

03 Jun 2016

ORDER

 

 

 

CONSUMER DISPUTES REDRESSAL FORUM-VI

(DISTT. NEW DELHI),

 ‘M’ BLOCK, 1^STFLOOR, VIKAS BHAWAN, I.P.ESTATE,

 NEW DELHI-110001

 

Case No.C.C./253/2013                                 Dated:

In the matter of:

JITENDER SHARMA

S/o Shri B.R. Sharma,

C-4D-58 B, Janak Puri,

New Delhi-110058.

        ……..COMPLAINANT

 

VERSUS

Royal Sunderam Alliance Insurance Co. Ltd.,

Through its Director

1505-1506, 15^th Floor, Ambadeep Building,

14, K.G. Marg, Connaught Place,

New Delhi-110001

               .... OPPOSITE PARTY

 

PRESIDENT: S.K. SARVARIA

ORDER

 

This complaint under section 12 Of the Consumer Protection Act, 1986 is filed by complainant alleging, in brief, that he obtained a mediclaim policy by the name "Health Shield Casualty Health Insurance" for himself covering risk of hospitalization. The OP after charging Rs. 6969/- as premium issued the policy with the coverage of Rs. 2,00,000/- effective from 18/3/2011 to 17/3/2012. On 1/9/2011 the complainant suffered with acute pain in stomach and visited his family Dr. V.P. Sachar, who advised him to get admitted to the hospital. On his advice complainant got himself admitted in City Hospital, Pusa Road, New Delhi, which is on cashless panel of OP insurance company. The complainant was thoroughly diagnosed in the hospital and was discharged on 6/9/2011. The complainant through Hospital applied for cashless medicalaim for his treatment, but OP avoided the same over one pretext or the another and the complaint was forced to pay Rs. 59,409/- to the hospital from his own pocket.

The complainant after discharge from the hospital submitted the entire original bills, reports, and supporting documents as per instructions of the OP company for the total claim of Rs. 59,409/-. The OP has intentionally repudiated the claim of the complainant, by letter dated 27/10/2011, which is a calculated attempt to avoid payment of the claim. The OP has not made the payment despite legal notice dated 9/11/2011 and issued by the complainant by registered post. The complainant has prayed for the following reliefs:

1. Direct the OP to pay th complainant the claim amount Rs,. 59,409/- as per the terms of the Insurance Policy alongwith interest @ 24% from 27/10/11 till the date of payment.
2. Direct the OP to pay a sum of Rs.30, 000/- as compensation to the complainant.
3.     Direct the OP to pay a cost of Rs. 5,000/- to the complainant.
4. Pass any other such order that this District Forum may deem fit and proper in the circumstances of the case.

The notice of the complaint was issued to the OP insurance company who contested the complaint and filed reply admitting that the complainant had taken a Health Shield Insurance Policy bearing Certificate No. HL 00033700000100 valid from 18/3/2011 to 17/3/2012. The OP has provided cover subject to specific terms and conditions as stipulated in the policy, which governs the instant claim. The complainant had made a claim with the OP under the aforesaid policy stating that he got admitted to City Hospital from 1/9/2011 to 6/9/2012 for pain in abdomen and diagnosed as Acute Colitis. The OP immediately appointed an investigator Dr. Jagroop Singh, who upon verifying the medical records confirmed that complainant was addicted to alcoholism since 20 years and was Chronic Smoker. It is also stated by the OP that complainant's admission notes taken from the hospital clearly show the complainant was a chronic alcoholic since past 20 years and further, the complaint was also a chronic smoker. So, the investigator recommended for repudiating the claim of the complainant as the complainant's claim for pre-existing ailment is inadmissible under the terms of the policy.

In the medico-legal expert opinion of Dr. R. Jaya Chandran, MD DNB-Medical Director M/S Trinity Acute Care Hospital also opined that the complaint was admitted with history of abdominal pain since one day. No history of fever, vomiting and loose motion. It is an acute onset of Gastritis only, as per records with history of Chronic Alcoholism, the claim can be repudiated. Therefore, the claim of the complainant for the sum of Rs. 59,409/- as expenses incurred for the said treatment was validly denied as per policy terms by the OP insurance company.

The OP has also alleged that the claim of the complainant was repudiated on 27/11/2011 and the present complaint is preferred by complainant on 12/3/2013, i.e. more than one year and four months later, therefore, OP is not liable to pay any sum on that count in the instant claim since the complainant has waived his right to use by not filing the complaint within 12 months from the date of repudiation in terms of the policy condition. The OP has denied other facts stated in the complaint and has prayed for its dismissal with costs.

In support of his case, the complainant filed his affidavit in evidence. on behalf of the OP insurance company, the affidavit in evidence of G. Vinay Parkash, an officer and authorised representative of the OP insurance company is filed. The OP has also filed written arguments.

We have heard learned counsel for the parties and have gone through the written arguments filed on behalf of the OP insurance company, record of the case and relevant provisions of law. No authority is produced from either side.

The basic facts in this complaint case are not in dispute. It is admitted that the complainant had taken a Health Shield Insurance Policy bearing Certificate No. HL 00033700000100 valid from 18/3/2011 to 17/3/2012. The OP has provided cover subject to specific terms and conditions as stipulated in the policy. There is also no dispute that the complainant was admitted to City Hospital from 1/9/2011 to 6/9/2012 for pain in abdomen and was diagnosed as Acute Colitis during the currency of insurance policy in question. There is also no dispute raised on behalf of the OP insurance company with regard to the medical expenses incurred by the complainant for his medical treatment indicated in the complaint.

In the backdrop of the above admitted position the contention on behalf of the complainant is that the discharge summary of City Hospital copy of which is filed by the complainant show that he was suffering from acute infective colitis with gastritis and this disease is no way related with the alcohol consumption or chronic alcohol consumption or smoking. So, repudiation of the insurance claim of the complainant by the OP insurance company is illegal and unjustified and shows inefficiency and deficiency in the services provided by the OP insurance company.

The contention on behalf of the OP insurance company is that the investigator Dr. Jagroop Singh and Dr. R. Jayachandran of M/s.Trinity Acute Care Hospital have in their reports stated that the complainant has a history of chronic alcoholism. So, the insurance claim should be repudiated. Accordingly, OP insurance company rightly repudiated the insurance claim of the complainant. So, the complaint is liable to dismissed.

We have carefully considered the respective contentions from both sides. In his letter to OP insurance company Dr. R. Jayachandran has stated that the case of complainant is of acute onset of Gastritis only, as per records with history of Chronic Alcoholism, the claim can be repudiated. But nowhere in this letter he has indicated, what were the records perused by him to give said opinion. Similarly, the copy of investigation report, dated 12/10/2011 of Dr. Jagroop Singh is filed on behalf of OP, which shows that the learned investigator visited the hospital and met with one Rita, he checked the papers, but they don't provide the IPD papers as it is not their policy. On checking the papers he came to know that patient was given excessive consumption of alcohol for the past 3-4 days and was on a trip to Gangtok. He has history of chronic alcoholic for 20 years and is smoker of 3-4 cigarettes per day. This investigation report is not backed by any document from the hospital in question or otherwise. When it is not the policy of the hospital concerned to show documents, how these documents were inspected by the investigator and how he can give any authentic report that the complainant was chronic alcoholic and chain-smoke, particularly when the discharge summary of the complainant from the same hospital does not indicate that the complainant is chronic alcoholic and is also smoker. The only document from hospital in question on record of this complaint case is the discharge summary filed by the complainant, which nowhere indicates that the complainant is alcoholic and smoker. In any case, if two opposite views emerge from material placed on record of this case regarding the question of complainant being alcoholic and smoker and from the record, one inference arises towards the complainant and the other view towards the OP insurance company contention that complainant is chronic alcoholic and smoker, the view in support of the complainant being consumer needs to be accepted by us.

The OP insurance company has also raised the question of limitation by alleging that the consumer complaint is filed after one year and four months from the date of repudiation of the insurance claim of the complainant, while according to the terms and condition of the policy, it should have been filed within 12 calendar months from the date of repudiation, so it is barred by time. Here, we again disagree with the OP insurance company as the condition in the insurance policy in question regarding filing of the claim within 12: calendar months from the date of repudiation of the insurance claim being against the provisions of Section 24 A of The Consumer Protection Act, which authorises a complainant to file complaint within two years of accrual of cause of action. In our view, the provisions of Section 24 A should prevail over any bilateral agreement between the parties to the present complainant on the question of limitation.

 

In view of the above discussion, we allow the complaint and direct the OP insurance company to make payment of Rs. 59,409/– along with simple interest at the rate of 10% per annum from the date of filing of the complaint till realisation of the said amount. We also direct the OP insurance company to make the payment in the sum of Rs. 10,000/– towards compensation for inconvenience suffered by the complainant, inclusive of litigation cost. In case the said amount of Rs. 10,000/- is not paid by the OP insurance company within a period of one month from date of receipt of copy of this order, the same shall be recoverable by the complainant from OP insurance company along with simple interest at the rate of 10% per annum from the date of this order till realisation of the said amount of Rs. 10,000/–. A copy of this order each be sent to both parties by post free of cost. This order be sent to server (www.confonet.nic.in ).

File be consigned to record room.    

 

Pronounced in open Forum on 03/06/2016.

 

 

(S K SARVARIA)

PRESIDENT

 

 

                                            (H M VYAS)

MEMBER