Delhi

New Delhi

CC/204/2012

Jatinder Lal Bhatia - Complainant(s)

Versus

M/S. The New India assurance Company Ltd. - Opp.Party(s)

20 May 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./204/2012                                                                                                      Dated:

In the matter of:

Mr. JITENDER LAL BHATIA,

A-I-B/15, LIG Glats,

Paschim Vihar,

New Delhi-110 063

        ……..COMPLAINANT

 

VERSUS

 

THE NEW INDIA ASSURANCE

COMPANY LTD.,

5^th Floor, Jeevan Bharti Bldg.,

124, Connaught Circus,

New Delhi-110 001

 

               .... OPPOSITE PARTY

 

PRESIDENT: S.K. SARVARIA

 

ORDER

                This complaint is filed by the Complainant and the complaint and documents indicate that the wife of the complainant Ms. Jyoti Bhatia was insured under the mediclaim policy No. 310900/34/09/11/00001315 dated 22/3/2010 she was admitted in Action Balaji Hospital due to sudden breathing problem and consequently stress on 7/7/2011 morning and was admitted in I.C.U. there. Within one or two hours, the TPA was informed by the hospital authorities alongwith estimate of the treatment Rs.58,000/- but the mediclaim bill were not paid by the OP not the reimbursement of medical expenses was done, despite letters of the complainant dated 30/7/11, 23/8/11, 31/8/11, 26/9/11 and 18/10/11. The complainant has prayed for the following reliefs:

1. Bill of Action Balaji Hospital                                    Rs.     32,517/-

(Other expenses within two months after discharge)

2. Consultation Fees of Dr. Singhal

On 16/7/11 & 25/8/11 @ Rs. 500/- per                   Rs.     1,000/-

•  
• Medicines @Rs.1000/0 p.m. approx.                       Rs.     2,000/-

Total                                                            Rs.     1,35,517/-

                                                                                                                   __

 

          The notice of the complaint was issued to OP who contested the complaint and filed WS admitting that the wife of the complainant was covered under the policy in question.  According to the OP the complainant was duly provided with the insurance policy alongwith its terms and conditions.   The OP did not dispute that the wife of the complainant was admitted to the hospital.  According to the OP in terms of condition 4.3 of the policy the claim of diabetic and hypertension was not payable for first two years of the policy i.e. 21/3/2011 to 20/3/2012 and had submitted the claim for the hospitalization of his wife for the period 7/7/2011 to 7/9/2011. The said claim was declined by TPA of the OP Company.  Since the wife of the complainant has obtained the treatment for diabetics and hypertension as such same was not covered under the policy for first two years so the claim was accordingly repudiated in terms of the clause No. 4.3 of the policy.  The OP has denied other facts stated in the complaint and has prayed for its dismissal.

In the rejoinder the complainant has denied the averments made in the written statements of the OP and has reaffirmed the facts stated in the complaint.

In support of his case, the complainant has filed his affidavit in evidence. On behalf of OP the affidavit in evidence of Sh. Pradeep, Sr. Divisional Manager of the OP is filed. In fact the case was reserved for final order after hearing arguments on behalf of the complainant on 9/5/14 as none appeared on behalf of OP for arguments on 9/5/14 .  Thereafter, the then Ld. President of this District Forum and one Ld. Member have retired necessitating, the matter fixed for re-arguments on 26/11/15.  The notices were issued to the parties, only complainant has appeared in person and none appeared for OP.

We have heard the complainant in person and have gone through his written argument, record of the case and relevant provisions of law.  

In this case, it is not disputed that the mediclaim insurance policy in question was obtained by the complainant for himself and his wife and son for the period 21/3/11 to 20/3/2012 which is Ex.C-I.  It is also not disputed that the wife of the complainant remained is hospital from 7/7/11 to 9/7/11 and complainant has spent the amount of Rs. 32,517/- i.e bill amount of Action Balaji Hospital.  The consultation fees of Dr. Singhal on 16/7/11 & 25/8/11 @Rs.500/- per consultation amounting to Rs.1000/- and medicines purchased by the complainant for treatment of his wife worth Rs. 2,000/- are also not specifically disputed.

In the backdrop of above admitted facts the only contention put forward in the pleadings and evidence filed by the OP is that as per clause 4.3 of the policy the claim in respect of Diabetics & Hypertension was not payable for the first and two years of the policy.  It was the first year of the policy of the complainant so the claim was rightly repudiated. But the discharge summary issued by Action Medical Institute in respect of Ms.Jyoti Bhatia clearly shows that she was non diabetic, non hypertensive and non smoker and she was admitted in HCC.  She was managed with Antiplatelets, NTG, Antibiotics and LMWH. She was taken up for CAG after consent on 8/7/2011 which showed normal coronaries. The procedure was uncomplicated. Therefore, we are, of the considered view that the discharge summary issued by Deptt. of Cardiology  of Action Medical Institute in respect of Ms. Jyoti Bhatia wife of the complainant does not indicate that she was suffering from hypertension and diabetic.  Merely because some tests were undertaken to know these diseases does not mean that she was suffering from these diseases to attract the relevant clause of the insurance policy justifying repudiation of claim of the complainant against the medical policy in question. Therefore, we are, of the considered view that the claim of medical reimbursement against of the mediclaim policy is wrongly repudiated by the OP Insurance Company.

In view of the above, we allow the complaint and direct the OP Insurance Company to make the reimbursement of the bill amount of Rs. 32,517/- and consultation fees of Dr. Singhal and medicines expenses total amounting to Rs.3,000/- be paid by the OP to the complainant alongwith 10% simple interest date of filing of the complaint till the realization of the said amount.  In addition we also direct the OP to make the payment of Rs. 30,000/- to the complainant inclusive of costs of litigation. If the said amount of Rs.30,000/- is not paid by the OP Insurance Company within one month of receipt of this order the same shall be recoverable by the complainant alongwith simple interest @10% p.a. from the date of this order till recovery of the said amount.

Copy of the order be sent to each of the parties free of cost by registered post.  This order be sent to server (www.confonet.nic.in ).

File be consigned to record room.    

Pronounced in open Forum on 20.05.2016.

 

 

 

 

(S K SARVARIA)

PRESIDENT

 

                                             (H M VYAS)

MEMBER