THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR
Consumer Complaint No. 179 of 2015
Date of Institution : 25.3.2015
Date of Decision : 07.10.2015
Vijay Kumar Kakkar aged about 53 years C/o A-One Travels, Ground Floor, Suraj Chand Cinema,Amritsar District Amritsar
...Complainant
Vs.
National Insurance Company Ltd., Divisional Office, Queens Road, Amritsar through Divisional Manager
National Insurance Company Ltd., Regional Office i, SCO 332-334, Sector 34-A, Chandigarh through Regional Manager
National Insurance Company Ltd., Regd.Office 3 Middleton Street, Kolkatta through Managing Director
Dedicated Healthcare Services TPA (India) Pvt.Ltd, Cambata Building (Eros Theatre Building) East Wing, 2nd Floor, 42 Maharishi Karvi Marg, Church Gate, Mumbai through its Director
....Opp.parties
Complaint under section 12/13 of the Consumer Protection Act, 1986
Present : For the complainant : Sh. Raghav Gulati , Advocate
For the opposite parties 1 to 3: Sh.Sandeep Singh Randhawa,Advocate
For opposite party No. 4 : Ex-parte
-2-
Quorum : Sh. Bhupinder Singh, President ,Ms. Kulwant Bajwa,Member
Order dictated by :-
Bhupinder Singh, President
1 Present complaint has been filed by Vijay Kumar Kakkar under the provisions of the Consumer Protection Act alleging therein that he has been obtaining mediclaim insurance policy from the opposite party and policies for the period from 19.1.2009 to 18.1.2010, 3.2.2011 to 2.2.2012 and 29.3.2013 to 28.3.2014 were issued by the opposite parties. During the policy period of 29.3.2013 to 28.3.2014 vide policy No. 404400/48/12/8500000809 with sum assured Rs. 5 lacs, complainant was admitted in Fortis Escort Heart Institute on 24.9.2013 and discharged on 28.9.2013. The complainant had to undergo Coronary Angiography, PTCA using stent in RCA, LAD & LCx and incurred an expenditure of Rs. 5,90,181/- on his treatment. Complainant has alleged that though the policy was cashless policy, even then the opposite partis did not pay the said amount to the hospital authorities. Complainant then lodged claim with the opposite parties, but the opposite parties did not pay any heed to the request of the complainant. Complainant also served legal notice upon the opposite parties on 13.1.2015 regarding payment of claim amount, but to no avail. Alleging the same to be deficiency in service complaint was filed seeking directions to the opposite parties to pay the claim amount of s. 5 lacs alongwith interest . Compensation of Rs. 2 lacs alongwith litigation expenses were also demanded.
2. On notice, opposite parties No. 1 to 3 appeared and filed written version in which it was submitted that complainant was admitted for Triple Vessel disease at Fortis Escort Heart Insitute and Research Centre for Coronary Artery Disease on 24.9.2013 and was dischargd on 29.9.2013. As per discharge card complainant is a known case of Coronary Artery Disease and underwent Coronary Angiography in 2011 which is a pre-existing. There is no continuity between the policy periods obtained by the complainant. The complainant obtained the policy in the year 2008 and then 2009 i.e. 19.1.2009 to 18.1.2010 but thereafter after a lapse of 16 days, complainant obtained the policy for the period from 3.2.2011 to 2.2.2012. Again the complainant obtained policy for the period from 29.3.2013 to 28.3.2014 ande as such there is no continuity between the policy periods. The policy inception is considered as 29.3.2013 and as per terms and conditions pre existing illness and its complications ae not covered and there is a four years waiting period for pre-existing disease, as such the claim of the complainant is not admissible as per clause 4.1 and 4.3 of the terms and conditions of the policy and there is no deficiency of service on the part of the opposite parties qua the complainant.
3. Opposite party No.4 did not appear and was proceeded against ex-parte vide order dated 26.5.2015.
4. Complainant tendered into evidence his affidavit Ex.CW1/A alongwith documents Ex.C-1 to Ex.C-11.
5. Opposite parties 1 to 3 tendered affidavit of Sh.S.K.Sharma, Divisional Manager Ex.OP1,2,3/1, copy of Insurance policies Ex.OP1,2,3/2 & Ex.OP1,2,3/3, policy schedule Ex.OP1,2,3/4, copy of policy Ex.OP1,2,3/5, copy of pre authorization form Ex.OP1,2,3/6, copy of letter dated 28.9.2013 Ex.OP1,2,3/7, copy of process sheet Ex.OP1,2,3/8, copy of lettr dated 28.9.2013 Ex.OP1,2,3/9, copy of repudiation letter Ex.OP1,2,3/10, Discharge Summary Ex.OP1,2,3/10-A, National Mediclaim Policy Ex.OP1,2,3/11.
6. We have carefully gone through the pleadings of the parties, arguments advanced by the ld.counsel for the parties and have appreciated the evidence produced on record by both the parties with the valuable assistance of the ld.counsel for both the parties.
7. From the record i.e.pleadings of the parties and the evidence produced on record by both the parties, it is clear that complainant got mediclaim Insurance policy bearing No. 404400/48/12/8500000809 from opposite party No.1 for the period from 29.3.2013 to 28.3.2014 with sum assured Rs. 5 lacs. The complainant further submitted that he had also obtained mediclaim policy from the opposite party for the period from 19.1.2009 to 18.1.2010 Ex.C-1 and for the period from 13.2.2011 to 12.2.2012 Ex.C-2. On 24.9.2013 complainant became ill and he was admitted in Fortis Escort Heart Institute for the treatment of his disease and was discharged on 28.9.2013 . During this period, complainant had to undergo Coronary Angiography, PTCA using stent in RCA, LAD & Lcx . The complainant spent a sum of Rs. 5,90,181/- as per bill dated 28.9.2013 Ex. C-6 of Fortis Escorts Heart Institute , New Delhi. The complainant lodged claimed with the oppposite party No.4 TPA but the opposite party repudiated the claim of the complainant vide letter dated 2.1.2014 Ex.OP1,2,3/10 on the ground that as per discharge card of the complainant the complainant is a known case of Coronary Artery Disease and underwent Coronary Angiography in 2011 which revealed single vessel disease, which is a pre existing . Inception of policy is considered as 29.3.2013, as per policy terms and conditions pre-existing illness and its complications are not covered and there is four years waiting period for pre-existing disease, as such the claim is not admissible under clause 4.1 and 4.3 of the terms and conditions of the policy Ex.OP1,2,3/11. Ld. Counsel for the complainant submitted that Fortis Escort Heart Institute authorities had issued certificae dated 26.9.2013 Ex.C-8 in which the treating doctor Dr. Ashok Seth has stated that complainant has no history of hypertension and Diabetes Mellitus. So the opposite party has wrongly repudiated the claim of the complainant which amounts to deficiency of service on the part of the opposite parties qua the complainant.
8. Whereas case of opposite parties No.1 to 3 is that complainant was admitted for Tripple Vessel Disease at Fortis Escort Heart Institute, New Delhi on 24.9.2013 and was discharged on 28.9.2013 as per discharge card Ex.OP1,2,3/10-A and as per this discharge card the complainant is a known case of Coronary Artery Disease and he underwent Coronary Angiography in 2011 which revealed single vessel disease which is a pre-existing disease. There is no continuity between the policy period obtained by the complainant from time to time. No doubt the complainant obtained the policy in the year 2008 and then in 2009. But after lapse of 16 days he got policy on 3.2.2011 to 2.2.2012 and then he obtained the policy for the period from 29.3.2013 to 28.3.2014 after a lapse of a period of one year and 55 days. So there was no continuity between the policy and the policy inception is considered as 29.3.2013 and as per terms and conditions of the policy pre-existing illness and its complications are not covered and there is a four years waiting period for pre-existing disease, to cover the same. Therefore, the claim of the complainant is not admissible under clause 4.1 and 4.3 of the terms and conditions of the policy Ex.OP1,2,3/11. Ld. Counsel for the opposite parties submitted that opposite parties have rightly repudiated the claim of the complainant vide letter dated 2.1.2014 Ex.OP1,2,3/10, as such there is no deficiency of service on the part of the opposite party qua the complainant.
9. From the entire above discussion , we have come to the conclusion hat no doubt the complainant obtained mediclaim policy from the opposite party for the period from 19.1.2009 to 18.1.2010 Ex.C-1 for the period from 3.2.2011 to 2.2.2012 Ex.C-2 and thereafter after a lapse of a period of more than one year the present mediclaim policy for the period from 29.3.2013 to 28.2.2014 Ex.C-3. So there was long gap between the policies. Therefore, the policy inception date is to be considered that of last policy as 29.3.2013 . As per the discharge card of the complainant issued by Fortis Escort Heart Institute, New Delhi Ex.OP1,2,3/10A, the complainant was admitted in Fortis Escort Hospital on 24.9.2013 and was dischaged on 28.9.2013, with Coronary Artery Disease and the Coronary Angiography (CAG) of the complainant done on 24.9.2013 revealed tripple vessel disease and the complainant underwent PTCA on 25.9.2013 using stent in RCA, LAD & LCx . This discharge card also proves that the complainant is a known case of Coronary Artery Disease as he underwent Coronary Angiography in 2011 which revealed single vessle disease. All this shows that the complainant was suffering from Coronary Artery Disease even in the year 2011 when he got his Coronary Angiography done in 2011 which revealed single vessel disease which is a pre existing disease. The policy inception is considered as 29.3.2013 and as per policy terms and conditions Ex.OP1,2,3/11 pre existing illness and its complications are not covered for four years waiting period as per clause 4.1 and 4.3. No doubt the complainant produced on record a certificae from Fortis Escort Heart Institute, New Delhi dated 26.9.2013 Ex.C-8 which states that the complainant has no history of Hypertension and Diabetes Mellitus as per their record . But the discharge card of the complainant issued by Fortis Escort Heart Institute Ex.OP1,2,3/10-A fully reveals that complainant underwent Coronary Angiography in 2011 which revealed single vessel disease . The complainant could not rebut this documentary evidence. So it stands fully proved on record that the complainant had pre-existing disease as he was suffering from Coronary Artery disease regarding which he had acquired Coronary Angiography which the complainant had undergone in 2011 which revealed single vessel disease. As per clause 4.1 of the terms and conditions of the policy Ex.OP1,2,3/11 the pre existing disease or its complications arising from pre existing disease are not covered for 48 months of continuous coverage. Ld.counsel for the complainant submitted that pre-existing disease is not a ground for the opposite parties for rejecting the claim of the complainant. More over the complainant was not aware of any pre-existing disease. In this regard he relied upon the rulings of the Hon'ble National Commission in Revision Petition titled as Praveen Damani Vs. Oriental Insurance Co.Ld 2006 NCDRC 64 as well as the ruling of the Hon'ble High Court of Delhi in case Hari Om Agarwal Vs. Oriental Insurance Co.Ltd. 2007(98) DRJ 246.
10. We have gone through these rulings . The facts of both these rulings are not similar to the present case. In case Praveen Damani Vs. Oriental Insurance Co. Ltd. (Supra) the complainant had succeeded in proving that he was unaware of the disease at the time of taking the policy, but in the present case the complainant had undergone CAG (Coronary Angiography) in 2011 which revealed single vessel disease as is evident from the facts mentioned in the discharge card of the complainant issued by Fortis Escort Heart Institute, New Delhi produced and relied upon by the complainant himself Ex.OP1,2,3/10-A. Similarly in case Hari Om Agarwal Vs. Oriental Insu.Co.Ltd (Supra) the complainant has declared his pre existing disease in the proposal form while taking the policy from the opposite party. But in the present case opposite parties have categorically stated that complainant has not mentioned his pre-existing disease in the proposal form while taking the policy in the year 2013-14 Ex.OP1,2,3/3. So, opposite parties have rightly repudiated the claim of the complainant vide letter dated 2.1.2014 Ex.OP1,2,3/10.
11. Resultantly we hold that there is no deficiency of service on the part of the opposite parties, as such the complaint is without merit and the same is hereby dismissed with no order as to costs. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.
7.10.2015 ( Bhupinder Singh )
President
/R/ ( Kulwant Kaur Bajwa)
