Delhi

East Delhi

CC/485/2014

TRIGWN BHATIA - Complainant(s)

Versus

NATIONAL INS. - Opp.Party(s)

17 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.  485/14

 

Shri Trigun Bhatia

56A, Street No. 12, Sarojini Park

Shastri Nagar, Delhi – 110 031                                              ….Complainant

 

Vs.

 

 

National Insurance Company Limited

Off.: 7^th floor, Hemkunt House

Rajender Place, New Delhi – 110 008                     …Opponent

 

 

Date of Institution: 24.05.2014

Judgment Reserved on: 17.10.2017

Judgment Passed on: 23.10.2017

 

CORUM:

Sh. Sukhdev Singh (President)

Dr. P.N. Tiwari  (Member)

 

Order By : Sh. Sukhdev Singh (President)

 

 

JUDGEMENT

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

2.       The facts in brief are that the complainant purchased Health Shield Insurance Policy for self and his wife, which he renewed for the period from 11.04.2013  to 10.04.2014 for a sum insured of             Rs. 5,00,000/- each and paid the consideration amount of               Rs. 18,570/- to the respondent.  They only gave a computerized policy without giving any terms and conditions.  In the month of June 2013, the wife of the complainant had some problem for which she was admitted in Fortis hospital on 15.06.2013.  She was discharged from the hospital on the same day and was advised for follow up. 

          The complainant informed the respondent immediately regarding hospitalization of his wife, but he was shocked when hospital authorities told the complainant that the company rejected the cashless facility.  The complainant contacted the respondent who was assured that after some formalities, the amount will be reimbursed to him.  The complainant paid a sum of Rs. 29,172/- to the hospital.  All the necessary papers and claim form were submitted to the respondent for Rs. 29,172/-, but respondent repudiated the claim vide letter dated 31.07.2013.  Thus, the complainant prayed for direction to respondent to pay an amount of Rs. 29,172/- alongwith 24% interest and to continue the policy of the complainant;             Rs. 50,000/- on account of deficiency in service on the part of the officers of respondent and Rs. 15,000/- towards cost of litigation.

3.       In the reply, OP have stated that they have issued the Parivar Mediclaim Policy bearing no. 360203/48/13/8500000156 valid from 11.04.2013 to 10.04.2014 alongwith terms and conditions, in favour of the complainant.  It was submitted that claim of the complainant lies under the Exclusion Clause no. 4.1 of the policy, which says that the Company shall not be liable to make payment under this policy in respect of any expenses whatsoever incurred by any person in connection with or in respect of pre-existing diseases when the cover incepts for the first time.  However, those diseases will be covered after four continuous claim free policy years. Pre-existing disease like Diabetes and Hypertension will be covered from the inception of the policy on payment of additional premium by the insured. 

          It was further submitted that the complainant concealed the medical condition of material facts at the time of taking of the policy or renewal of the policy.  Mrs. Ekta, wife of the complainant was a known case of Dysfunctional Uterine Bleeding for six months and Heavy period for last four years, before the inception of the policy.

          The policy was not in continuity for four continuous years as the policy was running since 2011 and the present claim arose in the 3^rd year of the policy, the claim of the complainant was repudiated vide letter dated 31.07.2013.

          It was also stated that the Park Mediclaim TPA Pvt. Ltd. vide its letter dated 23.07.2013 intimated the respondent that the claim was not payable under the Exclusion Clause 4.1.  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, complainant have examined himself.  He has deposed on affidavit and have narrated the facts stated in the complaint. 

          OP have examined Shri Anil Kumar Chopra, Div. Manager of OP, who have also deposed on affidavit.  He has narrated the facts, which have been stated in the WS.  He has also got exhibited documents such as copy of policy alongwith terms and conditions (Exhibit-R-1), treatment record of Mrs. Ekta dated 21.05.2013, issued by Dr. Chitra Setya (Exhibit-R-2), letter dated 23.07.2013 (Exhibit-R-3), proposal form (Exhibit-R-4) and copy of repudiation letter dated 31.07.2013 (Exhibit-R-5).

6.       We have heard Ld. Counsel for complainant as well as counsel for OP.  It has been argued on behalf of counsel for OP that claim of the complainant was rejected on the ground as the same was not admissible under Exclusion Clause 4.1 of the policy as wife of the complainant have pre-existing disease.  

          On the other hand, Ld. Counsel for the complainant have argued that the complainant was not having any pre-existing disease.         If the testimony of the complainant coupled with the discharge summary of Fortis Hospital is gone through, it is noticed that in the discharge summary, wife of the complainant Mrs. Ekta Bhatia remained in the hospital on 15.06.2013 and was discharged on the same day.  She was admitted for excessive bleeding during period with prolonged cycles since 6 months.  In the Past History, it has been stated as “nothing significant”.  However, pre-existing disease which have been stated by OP have been taken from the testimony of Shri Anil Kumar Chopra, Divisional Manager, who have deposed on oath and have got exhibited prescription of wife of complainant Mrs. Ekta Bhatia issued by Dr. Chitra Setya (Ex.R-2).  This prescription is of dated 21.05.2013 and in this prescription; there is no clarity as to the pre-existing disease which have been stated by OP.

          The fact that the prescription of Dr. Chitra Setya does not make it clear with regard to the disease and on the contrary, discharge summary of Fortis Hospital mentioned under the column Past History “nothing significant”, it cannot be said that the wife of the complainant was suffering from any pre-existing disease.  Therefore, there is no force in the arguments of Ld. Counsel for OP.  When the wife of the complainant was not suffering from any pre-existing disease, the rejection of claim on this ground amounts to deficiency in service.   By rejecting the claim of the complainant for the treatment of his wife, the complainant have suffered mental pain and agony for which he has to be compensated. 

          In view of the above, we order that National Insurance Company Ltd. (OP) shall pay an amount of Rs. 29,172 with 9% interest from the date of filing.  We further award compensation of Rs. 10,000/-, which includes the cost of litigation.

          The order be complied within a period of 45 days, if not complied, the amount of compensation of Rs. 10,000/- shall also 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