Punjab

Ludhiana

CC/14/755

Munish Singla - Complainant(s)

Versus

National Ins.Co.Ltd - Opp.Party(s)

12 Jun 2015

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, LUDHIANA.

 

                                                                    Complaint No: 755 of 07.11.2014

                                                                   Date of Decision: 12.06.2015

                    

Munish Singla aged 35 years s/o Sh.Bharat Bhushan Singla, Resident of Plot no.218, Ward No.6, Garden Colony, Morinda, District Rupnagar.

.…Complainant

Versus 

1. National Insurance Co. Ltd., having its Registered Office at 3, Middleton Street, Post Box no.9229, Kolkata-700071, through its Manager/Authorized Representative.

2. National Insurance Co. Ltd., having its Branch Office at D.A.B. Branch No.9, Kochar Market, Ludhiana, through its Branch Manager/Authorized Representative.

3. National Insurance Co. Ltd., having its Issuing Office: Unit 401603, G.T.Road, Miller Ganj, Ludhiana-141001, through its Manager/Authorized Person.

4. Park Mediclaim TPA Pvt. Ltd., B-15/179/1, Room no.11, Second Floor, Sona Complext, G.T.Raod, Miller Ganj, Ludhiana, through its Director/Authorized Person.

…..Opposite parties 

 

COMPLAINT UNDER SECTION 12 OF THE

CONSUMER PROTECTION ACT, 1986.

 

 

Quorum:             Sh.R.L.Ahuja, President

                             Sh.Sat Paul Garg, Member

 

Present:                Sh.Nitin Kapila, Advocate for complainant.

                              Sh.D.R.Rampal, Advocate for OPs.

 

 

ORDER

 

 (SAT PAUL GARG, MEMBER)

 

1.               Present complaint under Section 12 of The Consumer Protection Act, 1986 (herein-after in short to be referred as ‘Act’) has been filed by Sh.Munish Singla s/o Sh.Bharat Bhushan Singla, Resident of Plot no.218, Ward No.6, Garden Colony, Morinda, District Rupnagar (herein-after in short to be referred as ‘complainant’) against National Insurance Co. Ltd., having its Registered Office at 3, Middleton Street, Post Box no.9229, Kolkata, through its Manager/Authorized Representative and others (herein-after in short to be referred as ‘OPs’)- directing them to make the payment of Rs.2.00 lac i.e. the sum assured under the policy of relevant date alongwith interest @ 18% p.a. and to pay Rs.50,000/- on account of mental pain, agony and physical harassment alongwith any other additional or alternative relief to which the complainant is found entitled to.

2.                Brief facts of the complaint are that complainant got issued mediclaim policy no.40311/48/07/8500000013 effective from 9.4.07 to 8.4.08 from the OPs covering all the medical risks of the complainant and his family members. Subsequently, the complainant got the above said insurance policy renewed from time to time from the OPs for the periods 9.4.08 to 8.4.09, 9.4.09 to 8.4.10, 9.4.10 to 8.4.11, 9.4.11 to 8.4.12, 9.4.14 to 8.4.13, 9.4.13 to 8.4.14. On 20.3.11 the complainant was admitted in Surya Kidney Care, Sector 69, SAS Nagar, Mohali for treatment of his kidney problem. The complainant remained in the said hospital as indoor patient from 20.3.11 onwards and ultimately discharged on 2.4.11. During the period of admission and after discharge from the aforesaid hospital, the complainant spent huge amount on his treatment and medicines. After few days from the discharge from the hospital, complainant immediately lodged his claim with the OPs and submitted all the copies of the documents bills etc. with the OPs. But the claim of the complainant was not processed or sanctioned nor any positive reply was given by the OPs. The complainant wrote the Ops a letter requesting to pay the claim amount at the earliest, but the OPs have neither replied to the said letter nor paid the claim amount. Complainant also sent a legal notice dated 26.3.14 posted on 29.3.14, but despite the receipt of the said notice, the OPs have failed to do the needful and also failed to give any reply to the said notice. Complainant also sent reminder dated 8.5.14 posted on 9.5.14 to the OPs, but the OPs sent false and evasive reply dated 25.5.14, through his counsel. Claiming the above act as deficiency in service on the part of the OPs, the complainant has filed this complaint.

3.                On notice of the complaint, OPs appeared through their counsel and filed written statement taking preliminary objections that complaint is not maintainable in the present form; the complaint is false and frivolous one; the complaint is bad for non joinder and mis joinder of necessary parties; the complainant has not come to this Forum with clean hands and has suppressed the material facts. The claim of the complainant is not entertainable one and is not admissible. TPA Park Mediclaim OP4, vide letter dated 15.10.12 reported that alleged claim of the complainant is not admissible and be repudiated accordingly;  the complainant is stopped by his act and conduct from filing the present complaint; Intricate question of law and facts are involved in this case and this case cannot be summarily decided by this Forum. On merits submitted that the parties are governed by terms and condition of the Mediclaim Insurance Policy and that is the valid contract between the parties and it is one of the condition in the insurance policy that complainant is required to submit the claim and submitted the papers after expiry of 57 days from the date of admission in the hospital, which amounts to violation of mandatory condition of the policy. Complainant gave intimation dated 12.5.11 to OP3 on 13.5.11 for first time under this policy with regard to his treatment from 20.3.11 to 2.4.11 with Surya Kidney care hospital Mohali and on receipt of those documents the OP3 sent those papers to OP4 Park Mediclaim New Delhi for processing and settlement of the claim in accordance with the provisions of the law and in accordance with the terms and conditions of the insurance policy valid for the period of 9.4.10 to 8.4.11. M/s Park Mediclaim TPA vide letter dated 27.5.11 called upon the complainant to submit the certain documents and to reply the queries within 15 days from the said letter and it demanded account number, name of the bank, address of the branch, reports of all investigation vide which the complainant was diagnosed CKD for the first time, please send donor discharge summary, the reason for delay in submission of the claim documents after 30 days of discharge from the hospital, the complainant had not sent intimation about the hospitalization and he was required to intimate his hospitalization within 7 days, submit reasons for non compliance of this condition of the policy, record of treatment taken in prior hospitalization at Surya Kidney Care Hospital with discharge summary of previous hospitalization. The complainant received the above said letter and sent the reply dated 27.6.11 which was received by OP3 on 286.11 and by M/s Park Mediclaim TPA Pvt. Ltd. New Delhi on 1.7.14 but complainant has failed to give any satisfactory reply to the queries raised by Park Mediclaim TPA Pvt. Ltd. After receipt of the reply on 1.7.11 M/s Park Mediclaim TPA had called upon the complainant, vide letter dated 7.7.11 calling upon the complainant that the has failed to send intimation and documents of his claim within the stipulated period provided in the policy and was requested to inform the reason for delay in intimation and submission of documents. TPA Par Mediclaim vide letter dated 15.10.12 intimated the OP3 that claim of the complainant is not admissible since he did not intimate and submit the document within stipulated time period. On receipt of the decision of M/s Park Mediclaim TPA New Delhi and going through entire claim file the OP3 scrutinized the documents placed on the file and applied its mind and repudiated the claim of the complainant as he has failed to submit the claim within stipulated period and he submitted the claim after 57 days delay and there is violation of terms and conditions of the policy and repudiation letter treating the claim of the complainant as ‘No claim’ dated 29.3.13 was duly posted to the complainant. The grounds of repudiation of the claim by OP1 to OP3 are legal, valid enforceable and in accordance with the terms and conditions of the insurance policy and there is no deficiency in service and negligence on the part of OP1 to OP4. Further denying the contents of all other paras of the complaint, answering OPs prayed for the dismissal of the complaint.

4.                Ld. counsel for complainant has adduced the evidence by way of duly sworn affidavit of complainant Sh.Munis Singla Ex.CA, wherein, the same facts have been reiterated as narrated in the complaint and also attached documents Ex.C1 to Ex.C72. On the other hand, Ld. counsel for OPs has adduced the evidence by way of duly sworn affidavit of Sh.R.K.Wadhawan, Senior Branch Manager, National Insurance Co. Ltd., B.O., G.T.Road, Ludhiana Ex.RA, wherein, the same facts have been reiterated as narrated in the written statement and also attached documents Ex.R1 to Ex.R18.

5.                Ld. counsel for complainant argued that complainant availed the mediclaim policies from the OPs. During the subsistence of the coverage period of 9.4.10 to 8.4.11 of the policy, complainant was admitted in Surya Kidney Care, SAS Nagar, Mohali for the treatment of his kidney problem for the period 20.3.11 to 2.4.11 and he was insured for Rs.2.00 lac. However, all the medical records and documents was submitted with the OPs for the settlement of the claim, which is admitted by the OPs in para no.11 on merits of the written statement that complainant gave intimation dated 12.5.11 to OP3 on 13.5.11 for the first time. Further argued that there was a delay of 41 days and not 57 days, as alleged by OPs. As per Ex.R15 and Ex.R16 the claim is repudiated only on the ground that the intimation was received late which is wrong and baseless. As per the own version of the complainant he was not fully recovered from the disease even after the discharge from the hospital and sent the papers of the claim with the OPs immediately. Ld. counsel for complainant has also relied upon the Judgements passed in cases titled as National Insurance Co. Ltd. Vs Kulwant Singh- IV (2014) CPJ 62 (NC) passed by Hon’ble National Commission, New Delhi, National Insurance Co. Ltd. Vs Bobby Joseph and another- IV (2014) CPJ 360 (NC) passed by Hon’ble National Commission, New Delhi, Sahara India Commercial Corporation Ltd. and another Vs Gomti Devi and others- IV (2014) CPJ 255 (NC) passed by Hon’ble National Commission, New Delhi.

6.                Ld. counsel for OPs argued that the claim was filed after the elapse of 57 days from the date of discharge. Moreover, the complainant was having pre-existing disease as claim falls under the exclusion clause 4.2 of the policy.

7.                We have gone through the pleadings of the complainant as well as defence taken by the OPs and also perused the entire record placed on file.

8.                It is evident that the complainant availed the Mediclaim policies of the OPs since the year 2008. During the subsistence of the coverage of the policy for the period 9.4.10 to 8.4.11, the complainant suffered some kidney problem and was admitted in the Surya Kidney Care, SAS Nagar, Mohali, where he remained admitted from 20.3.11 to 2.4.11. It is admitted by the OPs that they received the claim papers and intimation on 13.5.11 meaning thereby that there was a gap of 41 days only not 57 days. Thus the averments made by the OPs the delay of 57 days is not tenable. From the perusal of Ex.R15 and Ex.R16, the claim has been repudiated only on the sole ground of delay of 57 days and further the plea made by the OPs about the pre-existing disease, which he has added later on in his own hand in para no.12 of the written statement about the pre-existing disease is also not proved, so is not tenable. Specially there was no mention of exclusion clause in repudiation letters Ex.R15 and Ex.R16. Further we find force from the judgement passed in case titled as National Insurance Co. Ltd. Vs Kulwant Singh- IV (2014) CPJ 62 (NC) passed by Hon’ble National Commission, New Delhi, National Insurance Co. Ltd. Vs Bobby Joseph and another- IV (2014) CPJ 360 (NC) passed by Hon’ble National Commission, New Delhi etc. produced on record by the complainant.  

9.                In view of the above discussion and the aforesaid judgement produced by the complaint, the present complaint is allowed and OPs are directed to settle and pay the claim of the complainant, as per the terms and conditions of the policy, which is allowable with no order as to cost. Order be complied within 30 days of receipt of the copy of the order, which be made available to the parties, free of costs. File be consigned to record room.

 

                             (Sat Paul Garg)                                 (R.L.Ahuja)

                                  Member                                          President

Announced in Open Forum.

Dated:12.06.2015 

Hardeep Singh