Before the District Consumer Disputes Redressal Commission, Bhiwani.

                                                              Complaint No.         :  261 of 2016

                                                              Date of Institution    :  27.12.2016.

                                                              Date of Decision      : 4.12.2020

Bijender Goel son of Late Sh. Jai Bhagwan Goel, aged about 41 years, C/o JVMGRR College, Charkhi Dadri, Tehsil Charkhi Dadri, District Bhiwani.

                                                                        ..………..Complainant.

                                                    Vs.

1. New India Assurance Co. Ltd., 87 Mahatma Gandhi Road, Mumbai(Maharashtra), through its Managing Director.

2. New India Assurance Co. Ltd., Branch Office at Circular Road, Opp. Civil Hospital, Bhiwani, Tehsil and District Bhiwani, Haryana through its Branch Manager.

3. Raksha TPA Pvt. Ltd., C/o Escorts Corporate Centre, 15/5, Mathura Road, Faridabad, Haryana, through its Managing Director.

……….Opposite parties.

COMPLAINT UNDER THE

 CONSUMER PROTECTION ACT,1986.

BEFORE:  SH.NAGENDER SINGH KADIAN, PRESIDENT.

                     SH.  SHRINIWAS KHUNDIA, MEMBER.

Present:        Sh. Abhishek Panwar, Adv. for the complainant.

Sh. Rajbir Singh, Adv. for OP Nos. 1 & 2.

Opposite Party No. 3 already exparte (vide order dated 16.1.2020).

                                         ORDER

NAGENDER SINGH KADIAN, PRESIDENT:

                     Brief facts of the present complaint, according to the complainant, are that he had obtained a health Insurance Policy namely “New India Floater Mediclaim” bearing No. 35380134162800000001 covering himself, his wife and children, which was issued on 21.3.2016 for one year i.e. from 1.4.2016 to 31.3.2017 from respondent no.2. The sum assured of policy was Rs. 2,00,000/- and complainant paid the requisite premium to the respondent no. 2. It is averred that during the validity of the said insurance policy, the complainant suffered some seizure disorder with DKA and hence, contacted a doctor at Maharaja Agrasen Hospital Punjabi Bagh, New Delhi, where he undergone treatment with Dr. Suresh Mittal and Dr. R.S. Raman, who recommended for immediate treatment of the complainant , which was conducted from 11.5.2016. It is averred that the above said policy being a cashless policy, the complainant disclosed this fact to the treating doctor on 10.5.2016 and handed over the relevant papers to the concerned hospital authorities. It is averred that when the hospital authorities contacted to the respondent no.3, a letter of denial of cashless facility was issued on the ground that disease is pre-existing and no policy continuation certificate provided. As such, it is averred that the complainant had to pay the hospitalization charges amounting to Rs. 92,287/- to the hospital authorities despite the fact that complainant was holding a valid insurance policy issued by respondent No.2.  It is averred that the complainant remained admitted in the hospital for operation on 11.5.2016 and was discharged on 17.5.2016. However, on dated 15.6.2016 the complainant lodged a claim bearing no. 90221617050911 for payment of hospitalization charges amounting to Rs. 92,287/- with the respondent No.3 and provided all the relevant documents but the same was also repudiated by the respondents on the basis of false excuses. The complainant also served a legal notice dated 16.8.2016 through his counsel Sh. Abhishek Panwar, Adv. of Bhiwani but the respondents failed to settle the claim of the complainant. Hence, this complaint and the complainant has prayed for directing the opposite parties to release the amount of Rs. 92,287/- alongwith interest @ 18% per annum from the date of filing the claim i.e. 15.6.2016 till actual payment and to pay Rs.1,00,000/- on account of compensation  and litigation expenses to the complainant.

2.             After registration of complaint, notice was issued to the opposite parties. Opposite parties No. 1 and 2 in their joint reply has submitted that as per Memorandum of understanding signed by the respondent no.3 with the answering respondents, the respondent no.3 has been nominated as the Third Party Administrator for arranging to process the claim filed by the insured. As per the version of the complainant, he lodged mediclaim No. 902216170050911 under mediclaim policy no. 35380134162800000001 and the same was recommended by respondent no.3 to the answering respondents for repudiation in accordance with the policy terms and conditions laid by the respondent No.1 and 2. It is also submitted that patient Bijender Goyal was found to have diagnosed case of Recurrent Seizure with Diabetic Ketoacidosis and had diabetic since seven years and policy was running in first year as date of inception of policy is since 1.4.2016 issued by respondents. It is averred that the complainant failed to submit any documents in support of portability as per the query letter sent by respondent no.3 to the complainant in this regard. Therefore, the claim was recommended for repudiation as per clause no. 4.1 laid down by the respondent no.1. Hence, it is averred that there is no deficiency in the part of answering respondents no.1 and 2. It is prayed that the present complaint may kindly be dismissed with costs.

3.             Opposite party no.3 appeared and filed its reply. Thereafter, none appeared on behalf of opposite party No.3 and as such opposite party No. 3 was proceeded against exparte vide order dated 16.1.2020 of this Forum (now Commission).  

                In its written statement, it is averred that the respondent No. 3 is a licenced TPA under IRDA Act 2001 to act as a facilitator for processing of claim filed by the insured. It is averred that the claimant entered into the contract/mediclaim with respondent Nos. 1 & 2 and not with the answering respondent and that the answering respondent is just a third party administrator who acts on the basis of policy entered between the complainant and the respondent Nos. 1 & 2. However, it is observed that for the remaining averments of reply filed by respondent Nos. 1 & 2, the respondent No. 3 supported the contents of their written statement.

 4.            The learned counsel for the complainant in his evidence has tendered affidavit Ex.CW1/A, documents annexure C1 to Annexure C-12 and has closed his evidence on dated 15.11.2018. On the other hand, ld. Counsel for the opposite party no.1 and 2 has tendered affidavit Ex.RW1/A, documents Annexure R1 to Annexure-R6 and closed the evidence on dated 19.12.2019.

5.             We have heard the arguments of learned counsel for the parties and have gone through material aspects of the case very carefully.

6.              After going through the facts of the case file, documents so placed on record and hearing the counsel of parties, we have observed that the respondent No. 3 has been nominated as the Third Party Administrator for processing the claim filed by the insured. In the present case, it is clear that the complainant had purchased a mediclaim policy bearing No. 35380134162800000001 (Annexure C-2) covering the complainant himself, his wife and children. It is the version of respondent Nos. 1 & 2 in their written statement that patient Bijender Goyal was found to have diagnosed case of Recurrent Seizure with Diabetic Ketoacidosis and had diabetis since 7 years and have submitted that the policy was running in first year and the inception date of policy was 1.4.2016 issued by respondents. It is further mentioned by the respondent Nos. 1 & 2 in their joint written statement that since the complainant had failed to submit any documents in support of portability as per query letter sent by the respondent No. 3 to the complainant in this regard, hence, the claim was recommended for repudiation as per clause 4.1 laid down by the respondent No.1 and that the claim of complainant has been rightly repudiated on account of violation of terms and conditions of the insurance policy taken by him.

                 From the perusal of above version mentioned by the respondent Nos. 1 & 2 in their written statement, it is apparent that it was well within the knowledge of the respondent Nos. 1 & 2 that the complainant have earlier mediclaim policies, as the perusal of documents placed on record show that the complainant have the medical policy for the period 28.3.2011 to 25.3.2012 (Annexure C-5) issued by Bajaj Allianz General Insurance Company Limited for a period of one year and they have charged an amount of Rs. 7243/-as premium amount from the complainant. Thereafter the policy was got renewed by the complainant well within time from Bajaj Allianz General Insurance Company Limited continuously upto 31.3.2016. These policies have been placed on record by the complainant as Annexure C-5 to Annexure C-9. The last policy was issued in favour of complainant’s family for the period from 25.3.2015 to 31.3.2016 and thereafter this policy was renewed by the respondent Nos. 1 & 2 for the period of one year i.e. from 1.4.2016 to 31.3.2017. The learned counsel of complainant submits that the complainant had disclosed all the required and relevant information to the agent of respondent No. 1 that he has earlier medical policies from about 6 years. We have observed that in the present case, the complainant have a medical policy initially for six years from Bajaj Allianz General Insurance Company Limited and thereafter it was renewed from the New India Assurance Company Limited and accordingly, the respondent Nos. 1 & 2 issued health insurance policy namely “New India Floater Mediclaim” policy in favour of complainant’s family. We have perused all the documents placed on record and found that there is no difference between the premium amount which was earlier paid by the complainant to the Bajaj Allianz General Insurance Company Limited and thereafter to the New India Assurance Company Limited. So, it can be easily presumed that nobody would give up the benefits accruing from the last six years of a mediclaim policy when all the ailments/diseases have been covered by Bajaj Allianz Insurance Company Limited and the complainant’s family/complainant purchased a new policy of the respondent No. 1 only to get the benefits of earlier policies, meaning thereby that the insurance policy was given by the agent of respondent Nos. 1 & 2 to the complainant family on the assurance that they will get all the benefits of previous policies also. So in our view, by not paying the benefits, for which the complainant had purchased a mediclaim policy to get the benefits of earlier policies, the respondent Nos. 1 & 2 have committed deficiency in service and the complainant is entitled to get the benefits of mediclaim policy from the respondent Nos. 1 & 2 along with compensation and the litigation expenses.

7.             In view of above mentioned facts and circumstances of the present case, we therefore, direct the respondent Nos. 1 & 2 to make the payment of Rs. 92,287/-to the complainant incurred by him on his treatment (amount is clear from claim form for health insurance policies of the New India Assurance Company Ltd duly attested by Dr. R.S. Raman of Maharaja Agrasen Hospital, New Delhi, placed on record as annexure C-10 and other bills placed on record) along with an interest @ 9% p.a. from the date of filing of the claim with the respondents i.e. 15.6.2016 till actual payment. The respondent Nos. 1 & 2 are also directed to pay Rs. 5000/-to the complainant as compensation on account of mental agony, physical harassment and hardship with litigation expenses of Rs. 5000/-and the compliance of order be made within 30 days from the date of the order. Certified copies of order be supplied to the parties free of costs and file be consigned to the record-room after due compliance.

Announced in open Commission

Dated: - 4.12.2020          

                               (Shriniwas Khundia)             (Nagender Singh)

                                          Member                            President,

                                                                         District Consumer Disputes

                                                                 Redressal Commission, Bhiwani.