DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, NORTH-WEST

GOVT. OF NCT OF DELHI

CSC-BLOCK-C, POCKET-C, SHALIMAR BAGH, DELHI-110088.

CC No: 714/2014

D.No._______________________                            Dated: _______________

IN THE MATTER OF:

SURENDER KUMAR S/o LATE SH. LAL CHAND,

(SINCE DECEASED)

THROUGH HIS LEGAL REPRESENTATIVE:

1. SURAJ KUMAR S/o LATE SH. SURENDER KUMAR,

2. Ms. SAPNA ARORA W/o SH. MAHENDER,

BOTH R/o G-7/58, GROUND FLOOR,

SEC.-16, ROHINI, DELHI-110089.

3. Ms. HEMA ARORA W/o SH. GULSHAN KUMAR,

R/o G-4/60, 1^st FLOOR, PKT-4, SEC.-16,

ROHINI, DELHI-110085. … COMPLAINANT (s)

Versus

1. NATIONAL INSURANCE CO. LTD.,

    (THROUGH ITS BRANCH MANAGER),

    9, 302, N.N. MALL, NEAR M2K CINEMA,

    SEC.-3, ROHINI, DELHI-110085.                                          

2. SUNRISE HOSPITAL,

    (THE MEDICAL SUPRINTENDENT),

    PLOT No.1, PKT-8-B, SEC.-15,

    ROHINI, DELHI-110085.

3. M/s PARK MEDICLAIM TPA PVT. LTD.,

    (THROUGH ITS MANAGER),

    702, VIKRANT TOWER, RAJENDERA PLACE,

    NEW DELHI-110008.                                       …OPPOSITE PARTY(IES)

CORAM:SH. M.K. GUPTA, PRESIDENT

               SH. BARIQ AHMED, MEMBER

     MS. USHA KHANNA, MEMBER

                                                            Date of Institution: 26.06.2014

                                                            Date of decision: 08.08.2019

SH. M.K. GUPTA, PRESIDENT

ORDER

1.       The complainant has filed the present complaint against the OP under Section 12 of the Consumer Protection Act, 1986 therebyalleging thatthe complainant has taken a Mediclaim Policy from OP-1 in 2010 an the complainant is regularly paying the premium from 2010 and the said policy is still alive bearing policy No. 360400/48/13/8500001058 and the sum insured if Rs.3,00,000/- for the said policy and the insured period was 02.07.2013 to 01.07.2014 and the said policy still alive. The complainant further alleged that the complainant had a severe pain and swelling in right foot in December-2013 and the complainant was immediately admitted to OP-2 i.e. Sunrise Hospital on 28.12.2013 and the treatment was done in OP-2 and was discharged from hospital on 14.01.2014 and the complainant was again admitted to OP-2 on 17.02.2014 for Skin Grafting and was discharged from hospital on 18.02.2014 and the total expenditure paid by the complainant on treatment is Rs.2,76,108/-. Thereafter, inspite of taking Mediclaim Policy, the complainant was compelled by OP-1 & OP-3 to get the treatment by arranging the money/amount from different sources with great difficulty and the total bill/amount of Rs.2,76,108/- was paid by the complainant for the treatment and the treatment is still going on. The complainant further alleged that the complainant applied/requested to OP-1 & OP-3 for allowing/releasing the claim but there is no proper response given by OP-1 & OP-3 and OP-1 & OP-3 are not allowing/releasing the claim on one pretext and other. The complainant further alleged that the complainant supplied all relevant copies of the documents to the OPs but the officials of the OPs are not giving proper response in this matter nor releasing the claim and in this regard, the complainant approached many times but no avail in deaf ears and the action of the OPs in refusing the legal claim amounts to deficiency in service on the part of OPs. 

2.       On these allegations the complainant has filed the complaint praying for direction toOPs to give/release the claim the amount of Rs.2,76,108/- alongwith interest @ 24% p.a. till its realization as well as compensation of Rs.3,00,000/- for causing mental agony and harassment and also sought Rs.25,000/- as costs of litigation.

3.       OP-1 & OP-2 have been contesting the complaint and have filed their separate reply/written statement. OP-1 in its written statement, the complaint is not maintainable and thus is liable to be dismissed. OP-1 further submitted that the complainant has firstly, obtained the Parivar Mediclaim Policy from OP covering himself aged about 53 years and and his son, aged 24 years bearing Insurance Policy no.360400/48/10/8500000782 valid for the period from 02.07.2010 to 01.07.2011 for a total sum insured for Rs.2,00,000/- and paid the requisite premium to OP. OP-1 further submitted that in Parivar Mediclaim Policy children upto 25 years only are considred as dependant and the complainant in his proposal form also declared that he is suffering from diabetes from 60 months and therefore, the complainant paid the extra premium to OP for the coverage of pre-existing in the proposal form and the said policy was again got renewed by the complainant on the same terms & conditions for a total sum insured for Rs.2,00,000/- being Mediclaim Insurance Policy no.360400/48/11/8500000880 valid for the period from 02.07.2011 to 01.07.2012. OP-1 further submitted that the complainant again approached OP for the renewal of his Parivar Mediclaim Policy but the said policy was not got renewed on the previous terms & conditions as the son of the complainant has admitted the age of 25 years and accordingly, as per the request of the complainant, the said policy was converted into the Individual Mediclaim Policy in which there is no extra premium is being required to be charged and the pre-existing diseases like Diabetes are not covered under the Individual Mediclaim Policy and the complainant got the Individual Mediclaim Policy being policy no.360400/48/12/8500001003 valid for the period from 02.07.2012 to 01.07.2013 for a total sum insured for Rs.3,00,000/- and the complainant has very cleverly not filed the complete policy with its terms & conditions as issued to him. OP-1 further submitted that the complainant has again got the policy renewed being policy no.360400/48/14/12/8500001058 valid for the period from 02.07.2013 to 01.07.2014 for a total sum insured for Rs.3,00,000/- and the policy is running in its 4^th year and the claim of the complainant is not admissible as per the terms & conditions of the policy of insurance and the same lies under the exclusion clause no. 4.1 of the terms & conditions of the policy and the exclusion clause is read as under: All diseases/injuries which are pre-existing when the cover incepts for the first time. However, those diseases will be covered after four continuous claim free policy years. For the purpose of applying this condition, the period of cover under Mediclaim Policy taken from OP-1 only will be considered. This exclusion will also apply to any complications arising from pre-existing ailment/disease/injuries. Such complications will be considered as a part of the pre-exisiting condition or disease. To illustrate, if a person is suffering from hypertension or diabetes or both bypertension and diabetes at the time of taking the policy. OP-1 further alleged that the claim of the complianant falls under the exclusion clause 4.1 of the policy and the same has very rightly been denied within the purview of the insurance policy as the policy is in its fourth year.

4.       OP-2 in its reply submitted that there is no cause of action in favour of OP-2 and thus is liable to be dismissed.

5.       The complainant filed separate rejoinders and denied the submissions of the OPs and furthersubmitted that the OPs have taken a misleading plea.

6.       In order to prove hiscase the complainant filed his affidavit in evidence and also filed written arguments. The complainant also placed on record copies of insurance policy issued by OP, copies of discharge cards dated 14.01.2014, 18.02.2014 & 07.04.2014 issued by Sunrise Hospital, copy of calculation amount of treatment & medicines, copies of medicine bills issued by Sunrise Pharmacuticals, copies of receipts issued by Sunrise Hospital, copy of cash memo/bill dated 14.01.2014 of Rs.1,26,550/- issued by Sunrise Hospital, copies of receipt no. 12431 dated 18.01.2014 of Rs.500/-, no.882 dated 18.01.2014 of Rs.300/-, no.12523 dated 22.01.2014 of Rs.4,000/-, no.12611 dated 27.01.2014 of Rs.500/-, no.12662 dated 02.02.2014 of Rs.500/-, no.12922 dated 10.02.2014 of Rs.500/-, no.12930 dated 12.02.2014 of Rs.500/-, no.4994 dated 17.02.2014 of Rs.10,000/-, no.5001 dated 18.02.2014 of Rs.8000/-, no.012 dated 03.04.2014 of Rs.4,000/-, no.029 dated 06.04.2014 of Rs.3,000/- & no.037 dated 07.04.2014 of Rs.5,200/- issued by Sunrise Hospital, copy of cash memo/bill no.353 dated 18.02.2014 of Rs.18,000/- issued by Sunrise Hospital, copies of receipt no.57003 dated 10.02.2014 of Rs.3,712/-, no.08039 dated 18.02.2014 of Rs.976/-, no.08000 dated 17.02.2014 of Rs.775/- & no.08001 dated 17.02.2014 of Rs.876/- issued by Sunrise Pharmacuticals, copy of receipt of Rs.3,200/- issued by Sunrise X-Ray & Diagnostic Centre, copy of cash memo/bill no.010 dated 07.04.2014 of Rs.12,200/- issued by Sunrise Hospital and ___________and copy of death certificate. 

7.       On the other hand on behalf of OP-1 Sh. P.K. Baksh, Dy. Manager for OP-1 filed his affidavit in evidence in which he denied the case of the complainant and submitted that there is no deficiency in service on the part of OP-1. OP-1 also filed copy of Policy Type: Individual Mediclaim/Parivar/Vidyarthi/Varishtha/PA, copies of insurance policy issued by OP-1 and copy of letter dated 06.05.2014 sent by OP-3. OP-1 has also filed written arguments.

8.       This forum has considered the case of the complainant as well asOP in the light of evidence and documents placed on record by the parties. The case of the complainant has remained consistent and there is nothing on record to disbelieve the case of the complainant.

The documents and evidence of the parties shows that the complainant was hospitalized in Sunrise Hospital for the treatment of pain and swelling in Right Foot during the period from 28.12.2013 to 14.01.2014 and the complainant was again admitted in the hospital on 17.02.2014 for Skin Grafting and was discharged from hospital on 18.02.2014.  This fact is not disputed by OP and the factum that the complainant has placed on record copies of documents which have been demanded by the TPA of OP vide letter dated 06.09.2011. It is hard to believe that the complainant would not have supplied the copies of documents as demanded vide letter dated 06.09.2011. Furthermore, as per the discharge summary issued by the hospital the patient/complainant was shifted to Gamma Knife suite and Leksell Stereotactic head frame was applied under local anesthesia in supine posture under Inj. Propofol sedation. The skull measurements were recorded and imaging of head (Stereotactic MRI) was obtained, the radiological images were then network transferred to Gamma Plan and treatment planning was performed and total 31 shots were delivered using seven 8 mm shots, nine 4 mm shots and fifteen mixed shots and 10% (4.4 Cubic cms) of tumor volume was delivered prescription dose 16 Gy. at 45% isodose configuration. Maximum dose at reference point was 35.6 Gy. and Optic pathwaysget less than 9 Gy. Patients tolerated the procedure well. Thus in view of above facts, it cannot be said that the complainant washospitalized without any justification. Thus, it appears that OP-1 has taken a false and bogus defence and in these circumstances, this forum is of opinion that OP-1 was not justifiedin denying the claim of the complainant. Thus, OP-1 is held guilty of deficiency in service.

9.       Thus, holding guilty for the same, we direct the OP-1 to: -

ii) To pay to the complainant an amount of Rs.50,000/- as compensation for harassment and mental agony

10. The above amount shall be paid by OP-1 to the complainantwithin 30 days from the date of receiving copy of this order failing which OP-1 shall be liable to pay interest on the entire awarded amount @ 10% perannum from the date of receiving copy of this order till the date of payment. If OP-1 fails to comply with the order within 30 days from the date of receiving copy of this order, the complainant may approach this Forum u/s 25 of the Consumer Protection Act, 1986.

11. Let a copy of this order be sent to each party free of cost as per regulation 21 of the Consumer Protection Regulations, 2005. Thereafter file be consigned to record room.

Announced on this 4^th day of February, 2019.

BARIQ AHMED                         USHA KHANNA                         M.K. GUPTA

   (MEMBER)                               (MEMBER)                         (PRESIDENT)

UPLOADED BY :- SATYENDRA JEET