Delhi

East Delhi

CC/773/2014

GAUTAM - Complainant(s)

Versus

N.I.C - Opp.Party(s)

25 Nov 2016

ORDER

DISTRICT CONSUMER DISPUTE REDRESSAL FORUM (EAST)

GOVT. OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, FIRST FLOOR,

SAINI ENCLAVE, DELHI – 110 092

 

C.C. NO. 773/14

 

Shri Gautam Mittal

S/o Shri N.K. Mittal

R/o C-207, Surya Naga

Ghaziabad – 201 011

Uttar Pradesh                                                                               ….Complainant

Vs.

 

1. National Insurance Company Limited

Divisonal Office

28, Scope Minar, 11^th Floor

Core-2, District Centre

North Tower, Laxmi Nagar

Delhi – 110 092                                                                                  ….Opponent

 

Date of Institution: 17.09.2014

Judgment Reserved on:25.11.2016

Judgment Passed on: 13.12.2016

 

CORUM:

Sh. Sukhdev Singh (President)

Dr. P.N. Tiwari  (Member)

Ms. Harpreet Kaur Charya (Member)

 

Order By : Shri Sukhdev Singh (President)

 

JUDGEMENT

The complainant Shri Gautam Mittal has filed a complaint under Section 12 of the Consumer Protection Act against the National Insurance Company Limited (OP) for deficiency in services.

2.        The facts in brief are that the complainant has the mediclaim policies of National Insurance Company having no.

For the period	Policy number	Premium	Sum insured
13.10.2007 to 12.10.2008	361600/48/07/8500000954	Rs. 1,179/-	Rs. 1,00,000/-
13.10.2008 to 12.10.2009	361700/48/58/8500001789	Rs. 1,179/-	Rs. 1,00,000/-
13.10.2009 to 12.10.2010	361700/48/09/8500001950	Rs. 1,157/-	Rs. 1,00,000/-
13.10.2010 to 12.10.2011	361700/48/10/8500002178	Rs. 1,157/-	Rs. 1,00,000/-
04.11.2011 to 03.11.2012	361700/48/11/8500002855	Rs, 2,859/-	Rs. 2,00,000/-
04.11.2012 to 03.11.2013	361700/48/12/8500002822	Rs, 6,076/-	Rs. 5,00,000/-

 

            These policies are stated to have been continuously purchased since 13.10.2007.  During the month of October’2011, complainant could not make the payment towards the premium for the policy in time and there was a gap of 22 days between the previous policy and policy for the period 04.11.2011 to 03.11.2012.  This gap was not deliberate.  Further, in the policy for the period from 04.11.2011 to 03.11.2012, OP have mentioned previous policy year/no. as 2010/361700/48/10/8500002178 and the OP has taken the proposal form and declaration date as 06.10.2008.  It has been stated that the OP have treated the policy from 04.11.2011 to 03.11.2012 in continuation of the previous policy for the period from 11.10.2010 to 12.10.2011.

            It has been stated that in the month of July’2013, the complainant started feeling minor pain in his stomach, which he thought to be normal stomach pain.  On 29.08.2013, he started suffering from severe pain and hematuria (blood in urine) and consulted Dr. Ashok Sharma of Indraprastha Apollo Hospital, Delhi.  Since, there was no effective relief, he consulted Dr. Ankur Gupta of Max Super Specialty Hospital, Shalimar Bagh, New Delhi on 03.09.2013.  After preliminary examination, he was admitted in Max Super Specialty Hospital.  Necessary tests were done and on 04.09.2013, surgery was conducted in which a ureteric stone was removed and a DJ stent was installed.  Stone found in kidney was not removed and the complainant was advised that the same would be removed after sometime.  Max Super Specialty Hospital charged an amount of Rs. 87,314/-.  All the documents were forward to OP/TPA but OP did not make payment and all the payment was made by the complainant. 

            For removal of stone in kidney, the complainant started taking the treatment at RG Urology and Laproscopy Hospital, Gagan Vihar, where he was admitted on 07.11.2013, DJ stent was removed, stone found in renal pelvis was identified and cleared through laser treatment for which an amount of Rs. 52,000/- was charged.  It has been stated that at Max Super Specialty Hospital, a ureteric stone was removed and a DJ stent was installed and removal of the stone in kidney was deferred, which was got done at RG Urology and Laproscopy Hospital. 

It has been further stated that the treatment taken at RG Urology and Laproscopy Hospital was part of the treatment, done at Max Super Specialty Hospital during the period 03.09.2013 to 06.09.2013 when the medical policy was in force.  Since the earlier payment of Rs. 87,314/-, made to Max Super Specialty Hospital was not reimbursed by OP, the complainant did not file the bills relating to treatment got done at RG Urology and Laproscopy Hospital to the OP for reimbursement.  OP vide its letter of dated 11.04.2014 closed the claim of the complainant by citing “As per policy Clause 4.3 claim falls within two year exclusion”.  Thus, it has been stated that OP have illegally and unjustifiably repudiated the claim of the complainant.  OP was liable to refund the complainant payment of Rs. 1,39,314/- (Rs. 87,314/- paid to Max Super Specialty Hospital and Rs. 52,000/- paid to RG Urology and Laproscopy Hospital) with 24% interest.

            A legal notice dated 13.05.2014 was served upon OP, which was replied by them on 13.06.2014.  Thus, the complainant has filed the present complaint with a prayer that OP be directed to pay the complainant Rs. 1,39,314/-.

3.        In the written statement, filed on behalf of National Insurance Company Limited (OP), they have stated that there was no deficiency on the part of respondent.  It has been stated that the complainant have not disclosed the clear facts.  He has given a cheque bearing no. 392782 dated 10.10.2011 for a sum of Rs. 2,859/-, which was got dishonoured.  Intimation of the same was sent to him on 27.10.2011, which fact has not been disclosed.  The complainant had taken a mediclaim insurance policy from 13.10.2007 till 12.10.2011.  Next premium under this policy was due on 13.10.2011.  Since the complainant did not pay the annual premium, which was due on 13.10.2011, the policy lapsed as per provisions contained in condition no. 12.  As the complainant did not pay the premium and allow his policy be lapsed with effect from 13.10.2011, on receiving the premium on 04.11.2011, a fresh policy bearing no. 361700/48/11/8500002855 valid from 04.11.2011 to 03.11.2012 was issued, which was considered as a new policy and valid as per terms and conditions of the policy.  It has been stated that since the complainant has not completed two years of the insurance policy, the disease suffered by the complainant falls under exclusion clause of 4.3 of the terms and conditions of the mediclaim insurance policy.  It has been stated that as the claim has been lodged for the expenses incurred during the period 04.09.2013 to 06.09.2013 for treatment of stone in kidney at Max Super Specialty Hospital and again on 07.11.2013 to 08.11.2013 in RG Urology and Laproscopy Hospital, the treatment of the complainant in RG Urology and Laproscopy Hospital for admission on    7-8/11/2013 did not cover the policy, which was valid up to 03.11.2013.  Therefore, the same falls under clause 4.3 of the policy terms and conditions.  Accordingly, the claim was repudiated and complainant was duly informed vide letter of dated 11.04.2014.  Other facts have also been denied. 

4.        The complainant has filed rejoinder to the WS of OP, wherein he has controverted the pleas taken in the WS and reasserted his pleas.

5.        In support of its complaint, the complainant has examined himself on affidavit.  He has also got exhibited copy of documents such as insurance policies (Ex.CW1/1), copy of prescription of Dr. Ashok Sharma (Ex.CW1/2), treatment papers of Max Super Specialty Hospital (Ex.CW1/3), bill of Rs. 87,314/- of Max Super Specialty Hospital (Ex.CW1/4), discharge summary of Max Super Specialty Hospital (Ex.CW1/5), reports of RG Urology and Laproscopy Hospital (Ex.CW1/6), bill of Rs. 52,000/- of RG Urology and Laproscopy Hospital (Ex.CW1/7), discharge summary of RG Urology and Laproscopy Hospital (Ex.CW1/8), letter of M/s. Raksha TPA Pvt. Ltd. (Ex.CW1/9), letter of repudiation of claim by the insurance company (Ex.CW1/10), legal notice sent to the insurance company (Ex.CW1/11) and its reply by the insurance company (Ex.CW1/12). 

            In defence, insurance company have examined Shri V.K. Bhatia, Assistant Manager, who has deposed on affidavit.  He has narrated the facts, which have been stated in the WS. 

6.        We have heard Ld. Counsel for the complainant.  No one appeared to argue on behalf of National Insurance Company.  The main plea, taken by the insurance company has been that the complainant has not completed two years of the insurance policy.  The disease suffered by the complainant falls under Exclusion Clause 4.3 of the terms and conditions of the mediclaim insurance policy.  It has further been stated in the evidence of OP that the treatment taken at RG Urology and Laproscopy Hospital for admission on 7-8/11.2013 did not cover the policy, which was valid up to 03.11.2013. 

            Firstly, the treatment taken at RG Urology and Laproscopy Hospital is taken up for which the complainant did not prefer any claim with the insurance company.  For this, a look has to be made to the policy.  Latest policy, which was of no. 361700/48/12/8500002822 for the period 04.11.2012 to 03.11.2013, has been got collectively exhibited in the testimony of the complainant as Ex.CW1/1.  When the complainant himself has stated that policy no. 361700/48/12/8500002822 was for the period 04.11.2012 to 03.11.2013 his admission in RG Urology and Laproscopy Hospital from 7-8.11.2013 was not covered under the policy.  Therefore, for this claim, the complainant cannot make the insurance company liable.  Thus, his this claim for an amount of Rs. 54,000/- goes.

            Coming to the second claim, made by the complainant for an amount of Rs. 87,314/- at Max Super Specialty Hospital, the repudiation of claim has been made by the insurance company on the ground that treatment of disease, such as calculus disease were not payable for the first two years of the operation of the policy.  For this, it has to be seen as to whether the policy issued for the period 04.11.2011 to 03.11.2012 was in continuation of the subsequent policy for the period 4.11.2012 to 3.11.2013. 

            The complainant got admitted at Max Super Specialty Hospital on 04.09.2013 and was discharged on 06.09.2013.  He was treated for right ureteric and renal calculus.  The plea taken by the insurance company has been that since the complainant did not complete two years of policy, his claim was rejected as falling under Clause 4.3, Exclusion Clause.  The plea taken on behalf of the complainant has been that the policy for the period 13.10.2010 to 12.10.2011 was got renewed after a gap of 22 days.  Whether, this revival of policy for the period 04.11.2011 to 03.11.2012 and subsequent policy for the period 04.11.2012 to 03.11.2013, during which the complainant was treated is to be considered as continuation of the policy or fresh policy.  Though, in the documents placed on record, it has been shown in the policy issued from time to time, the proposal form and declaration date as 06.10.2008, but the fact remains as to whether the complainant got this gap period of   22 days condoned for issuance of the policy effective from 04.11.2011 to 03.11.2012. 

There is no averment in his complaint as to whether he has submitted any application for condonation of delay for getting it condoned.  When there has been no averment made in the complaint, it cannot be said that the delay of 22 days was condoned by the insurance company.  When the said delay has not been condoned by the insurance company, the question of continuation of policy for the period 04.11.2011 to 03.11.2012 in continuation of its earlier policies for the period commencing from 13.10.2007 to 12.10.2010 does not arise.  Not only this, even it has come in the testimony of Shri V.K. Bhatia, Assistant Manager of National Insurance Company that the complainant issued cheque no. 392782 dated 10.10.2011 for a sum of Rs. 2,859/-, which was got dishonored by the bank, intimation to this effect was sent to the complainant on 27.10.2011. 

When the complainant himself has allowed his policy to lapse, later on, he cannot claim that the revival of policy was in continuation of its earlier policies.  When the policy was not in continuation of its earlier policies, the rejection of claim by the insurance company treating the policy for the period 04.11.2011 to 03.11.2012 as a fresh policy and claim of the complainant falling under the Exclusionary Clause cannot be said to be unjustified.   When the complaint of the complainant fails on the ground that the policy for the period 04.11.2011 to 03.11.2012 was a fresh policy and not a continuing policy, the treatment taken by the complainant at Max Hospital was excluded under the exclusionary clause, there was no necessity to go into the question of pre-existing disease, which was a bone contention of the complainant.  Therefore, the judgement in Mr. Virender Kumar Jain Vs. M/s. Oriental Insurance Co. Ltd., Appeal No. 1223/2002 of Hon’ble State Commission, Bajaj Allianz General Insurance Co. Ltd. Vs. Shri Kamal Kumar Rateria, Revision Petition no. 4484 of 2010 of NCDRC and National Insurance Company Limited Vs. Radhey Shyam Balwada, Revision Petition no. 3258 of 2013 of NCDRC are not attracted to the facts of the case.   

In view of the above, we are of the opinion that there was no deficiency on the part of insurance company in rejecting the claim of the complainant.  Therefore, the complaint of the complainant deserve its dismissal and the same is dismissed with cost of Rs. 5,000/-.

            Copy of the order be supplied to the parties as per rules.

File be consigned to Record Room.

 

(DR. P.N. TIWARI)                                              (HARPREET KAUR CHARYA)

Member                                                                                Member    

 

    (SUKHDEV SINGH)

          P resident