Delhi

East Delhi

CC/893/2013

KUSUM SHARMA - Complainant(s)

Versus

NATIONAL INS. CO. - Opp.Party(s)

25 Oct 2017

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM (EAST)

GOVT. OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, FIRST FLOOR,

SAINI ENCLAVE, DELHI – 110 092

 

 

C.C. NO.  893/13

 

Smt. Kusum Sharma

W/o Late Shri Manmohan Pandey

R/o D-187, Pocket-E

Dilshad Garden, Delhi – 110 095                                           ….Complainant

 

Vs.

 

National Insurance Company Ltd.

11.  

North Tower, Core-2

Laxmi Nagar District Centre

Delhi – 110 092                                                                 …Opponent

 

 

Date of Institution: 08.10.2013

Judgment Reserved on: 25.10.2017

Judgment Passed on: 31.10.2017

 

CORUM:

Sh. Sukhdev Singh (President)

Dr. P.N. Tiwari  (Member)

 

Order By : Sh. Sukhdev Singh (President)

 

 

JUDGEMENT

          This complaint has been filed by Smt. Kusum Sharma against National Insurance Company Limited (OP), under Section 12 of the Consumer Protection Act, 1986. 

2.       The facts in brief are that the complainant entered into a term policy by paying an amount of Rs. 5,792/-, vide policy no. 361700/48/12/8500002221 dated 05.09.2012 for a period of 12 months commencing from 07.09.2012 to midnight 06.09.2013 with benefits in hospital indemnity for Rs. 2,00,000/-.  Cashless member   i-card no. M5813235902 was provided by OP for the complainant and her husband. 

          It was stated that on 07.11.2012, husband of the complainant developed medical problem and admitted in Max HealthCare Super Specialty Hospital, New Delhi where he was diagnosed CA Rectum and remained in the hospital upto 11.11.2012.  During that period, complainant spent Rs. 78,568/- from her pocket and filed claim for the said amount vide claim Ref. No. 58221213129917 in the office of OP.    The complainant was shocked to receive rejection letter dated 28.12.2012 from the office of the TPA Raksha of OP with the remarks “patient is K/C/O CA rectum since 4 years, while inception of policy is since 07.09.2010 (1^st year).  The disease and related complication prior to inception of policy is non payable, hence this claim stand non tenable”. 

          It was mentioned that OP passed two mediclaim bills for the husband of the complainant time to time and paid a sum of             Rs. 22,876 on 31.01.2012 and Rs. 13,835/- on 09.06.2012.

          Even after the repudiation of the claim, the complainant visited office of OP, but nothing was done.  Hence, the complainant has prayed for direction to OP to pass claim of Rs. 78,568/- with interest @ 18%; pay Rs. 1,00,000/- compensation on account of mental agony and harassment and Rs. 25,000/- towards cost of complaint.

3.       In the reply, OP have stated that they were liable to reimburse the amount according to the terms and conditions of the policy and opinion of the doctors of TPA.  They have further stated that as per the documents, filed by the complaint, the disease was pre-existing as the patient was suffering from the disease for the last 4 years and at the time of issuance of the policy also.  Other facts have also been denied.   

4.       In support of its complaint, complainant have examined herself.  She has deposed on affidavit and have narrated the facts stated in the complaint.  She has also got exhibited documents such as copy of policy and cashless member i-card (Annex. C-1 and C-2), copy of hospital receipt, lama/discharge summary, inpatient bill, investigation detail and lab reports (Annex. C-3 to C-8), copy of rejection letter (Annexure C-9), copy of previous policies, hospital bill and statement of accounts (Annexure C-10 to C-15 colly.) and copy of death certificate (Annex. C-16).

          In defence, OP have examined Shri Ajay Kumar, Assistant Manager of OP, who has deposed on affidavit.  He has narrated the facts which have been stated in the WS.  He has also got exhibited documents such as terms and conditions of the insurance policy    (Ex. RW-1/1). 

5.       We have heard Ld. Counsel for the parties and have perused the material placed on record.  It has been argued on behalf of OP that the husband of the complainant was having pre-existing disease which led to repudiation of his claim. 

          On the other hand, counsel for the complainant have argued that he was not suffering from any pre-existing disease.  He has further argued that even National Insurance Company have passed his two mediclaim for a sum of Rs. 22,876/- against bill no. IPD/C/11/4728 dated 19.12.2012 of Deepak Memorial Hospital and Rs. 10,835/- of Pushpawati Singhania Research Institute.  Thus, he has argued that by paying the earlier bills, the company was estopped from raising any objection for the present bill. 

          To appreciate the arguments of Ld. Counsel for the parties; a look has to be made to the evidence on record.  If the documents placed on record by the complainant such as bill of Deepak Memorial Hospital and Pushpawati Singhania Research Institute are looked into, it is noticed that in the discharge summary of Deepak Memorial Hospital, husband of the complainant was admitted in this hospital with complaints of loose watery stool multiple episodes.  Nothing has been mentioned with regards to any past history of any disease. 

          Further, discharge summary of Pushpawati Singhania Research Institute, it was stated under the column ‘Past and Family History’ that the husband of the complainant was admitted in Deepak Memorial hospital earlier on December 2011 for the management of enteric fever and enteritis.  It has also been stated that there was a history of Fissure in Ano.  However, it is only in the report of Max Hospital, the husband of the complainant have been stated to be a case of CA Rectum.  Thus, from the analysis of these three bills, it comes out that husband of the complainant was not suffering from CA Rectum in the year 2012 when he was admitted in Pushpawati Singhania Research Institute as well as Deepak Memorial Hospital in the year 2011.  It is only in the year 2012 when he was admitted in Max Hospital, he has been diagnosed as CA Recturm.  Thus, it cannot be said that the husband of the complainant was susffering from any pre-existing disease. 

          Not only that, even the complainant have stated in his complaint that his earlier two bills of Deepak Memorial Hospital and Pushpawati Singhania Research Institute have been paid by the National Insurance Company.  No categorical reply have been given by National Insurance Company in their Written Statement to this fact.  The fact that when National insurance Company have paid his earlier bills, the question of non-payment of the present bill on the ground of pre-existing disease does not arise.  Even otherwise also, CA Rectum cannot be said to be a pre-existing disease as it develops only after a prolonged period.  The husband of the complainant even if was suffering from fissure in Ano, as reported in the discharge summary of Pushpawati Singhania Research Institute, which was not stated in Deepak Memorial Hospital discharge summary and the CA Rectum reported in the Max Hospital are two different diseases, though, it might have developed from the disease of fissure in Ano.  Hence, husband of the complainant cannot be said to be suffering from any pre-existing disease.  Thus, the rejection of the claim by the national Insurance Company, without any reason, amounts to deficiency in service.   By rejecting the claim of the complainant, without any reason, she has suffered from mental pain and agony for which she has to be compensated.

          In view of the above, we order that complainant be paid a sum of Rs. 78,568/-.  Further, she is awarded an amount of Rs. 30,000/- on account of mental pain and suffering, which includes the cost of litigation. 

            The order be complied within a period of 45 days. If not complied, the total amount of Rs. 1,08,568/- shall carry 9% interest from the date of order.          

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

          File be consigned to Record Room.

 

(DR. P.N. TIWARI)                                                             (SUKHDEV SINGH)

     Member                                                                                   President