Delhi

North East

RBT/CC/300/2022

SH KEWAL KRISHAN - Complainant(s)

Versus

NATIONAL INSURANC CO. LTD. - Opp.Party(s)

04 Sep 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION: NORTH-EAST

GOVT. OF NCT OF DELHI

D.C. OFFICE COMPLEX, BUNKAR VIHAR, NAND NAGRI, DELHI-93

Complaint Case No. 300/22

 

 

 

In the matter of:

		Shri Kewal Krishan R/o L-2/79, Shastri Nagar, North West, New Delhi		Complainant
		Versus
	1.         2.	National Insurance Co. Ltd. New Delhi Division, XIV D P Block, Second & Third Floor, Pitampura, LSC, New Delhi   MD India Healthcare Service TPA Pvt. Ltd. Delhi Office:- Plot No. 18, Ground Floor, Ganga Plaza, Puse Lane, Karol Bagh, New Delhi-110005		Opposite Party
			DATE OF INSTITUTION:         JUDGMENT RESERVED ON:                           DATE OF ORDER:		14.09.18 24.02.23 04.09.23

 

CORAM:

Surinder Kumar Sharma, President

Anil Kumar Bamba, Member

Ms. Adarsh Nain, Member

ORDER

Ms. Adarsh Nain, Member

The Complainant has filed the present complaint under Section 35 of the Consumer protection Act, 2019.

Case of the Complainant

1. The case of the Complainant as revealed from the record is that the Complainant has taken hospitalization benefit policy from 2008 to 2009 for a premium of 1 lakh and remained continued till 2012. In 2013, the Complainant extended the premium amount from Rs. 1 lakh to Rs. 1.5 lakh vide policy no. 360700/48/13/8500000386, thereafter; the policy amount was increased from 1.5 lakh to Rs. 3 lakhs. Further the Complainant extended the policy amount from Rs. 3 lakhs to Rs. 4 lakhs from 2013 to 2016 and then the amount was increased to tune of Rs. 5 lakhs till 2019. In 2016, the Complainant met with an accident and got treatment from St. Stephen’s Hospital vide X-ray report dated 20.06.17. The Complainant stated that in June 2018, Complainant found difficulty in walking and got check up from Medanta Hospital. The treatment was conducted by Dr.Sudhir Dubey and the Complainant was told that there are problem of D11 & D12 with paraparesis and for this, the Complainant shall have to get surgery. The date for surgery of the Complainant was given 19.06.18. On 19.06.18 Complainant got admitted in Medanta hospital and his surgery was done by Dr. Sudhir Dubey and some plates were planted in spine of Complainant. The total medical bill was for Rs. 4,05,102/-. The Complainant stated that he approached Opposite Party for claiming his amount but Opposite Party paid Rs. 75,000/- to hospital and balance amount of Rs. 3,30,102.88/- was paid by Complainant. The Opposite Party refused to pay the balance amount of Rs. 3,30,102.88/-. The Complainant stated that Opposite Party repudiated the claim by falsely observing that the Complainant has concealed the disease which was being suffered by him prior taking the policy. However, as per the report issued by the competent doctor, the said disease has developed just one year back. The Complainant stated that Complainant had served legal notice to Opposite Parties dated 01.08.18 through speed post and courier. The Opposite Parties received the legal notice but neither Opposite Parties replied to notice nor complied the same.  Hence, this shows deficiency on the part of Opposite Parties. Complainant has prayed for the balance amount of medical expensed of Rs. 3,30,102.88 /-.He further prayed for Rs. 1,00,000/- as compensation and Rs. 15,000/- for litigation expenses.  

Case of the Opposite Party No.1

2. The Opposite Party No.1 contested the case and filed written statement.  Opposite Party No.1 contended that the claim has been rightly repudiated by them as per exclusion under clause 4.1 of the insurance policy. It has been submitted by Opposite Party No.1 that as per the IPD paper provided by hospital, it was found that the patient had history of fall from bike in 2013 and destroyed Right hip joint with degenerative changes. Since the present ailment has proximal relation with the past ailment so the disease was found pre-existing and the claim was denied. In view of above, Opposite Party No.1 prays that there being no deficiency on their part, the complaint deserves to be dismissed.
3. It is to be noted that service of notice was affected on Opposite Party No.2, however, none entered appearance on their behalf and did not contest the case.

 

 

Rejoinder to the written statement of Opposite Party No.1

4. The Complainant filed rejoinder to the written statement of Opposite Party wherein the Complainant has denied the pleas raised by the Opposite Party and has reiterated the assertion made in the complaint.

Evidence of the Complainant

5. The Complainant in support of his complaint filed his affidavit wherein he has supported the averments made in the complaint.

Evidence of the Opposite Party No.1

6. In order to prove its case Opposite Party No.1 has filed affidavit of Shri Raghunath Pawar, wherein the averments made in the written statement of Opposite Party No.1 have been supported.

Arguments & Conclusion

7. We have heard the Ld. Counsel for the Complainant. We have also perused the file and the written arguments filed by the Complainant and Opposite Party No.1.  
8. The case of the Complainant is that Opposite Party repudiated his claim by falsely observing that the Complainant has concealed the disease which was being suffered by him prior to the the policy. However, as per the report issued by the competent doctor, the said disease has developed just one year back. The Complainant stated that he approached Opposite Party for claiming his amount but Opposite Party paid Rs. 75,000/- to hospital and balance amount of Rs. 3,30,102.88/- was paid by Complainant.
9. On the other hand, Opposite Party No.1 contended that the claim has been rightly repudiated by them as per exclusion under clause 4.1 of the insurance policy. It has been submitted by Opposite Party No.1 that as per the IPD papers provided by hospital, it was found that the patient had history of fall from bike in 2013 and destroyed Right hip joint with degenerative changes. Since the present ailment has proximal relation with the past ailment so the disease was found pre-existing and the claim was denied. It has been contended by the Opposite Party No.1 that they have rightly rejected the remaining claim on the ground of pre- existing disease under condition 4.1.
10.  The contention of the Opposite Party No.1 is that the remaining claim of the Complainant has been rejected on the ground of pre-existing disease under condition 4.1 of the subject policy. We have carefully perused the material on record as well as the pleadings and find that Opposite Party No.1 has not filed any supporting document such as duly filled Health declaration form/ Proposal form etc. showing that the Complainant concealed the pre-existing disease at the time of taking the subject policy. Therefore, their contention cannot be relied upon. It is also relevant to mention here that the admitted facts of the case reveal that the Complainant is having continuous health coverage for the past 9 years from Opposite Party No. 1 without any fail and the Opposite Party No.1 is receiving premium for a considerable period of time.
11. Since Opposite Party No.1 had come out with the case that the Complainant did not disclose his pre-existing disease, it was for them to produce cogent evidence to prove the allegation. The Opposite Party No.1 has failed to prove their case and has been at fault by rejecting a genuine claim under a valid policy.
12.   In view of above discussion, we are of the considered view that Opposite Party No.1 has been deficient in services to the Complainant by rejecting the genuine remaining claim of the Complainant. 
13.  Thus we allow the present complaint and direct the Opposite Party No.1 to pay to the Complainant the balance amount of Rs. 3,30,102.88/- along with 6% interest from the date of rejection which is 26.06.2018 till its recovery. The Opposite Party is further directed to pay Rs. 35,000/- towards compensation and litigation cost along with 6 % interest from the date of this order till its recovery.
14. Order announced on 04.09.23.

Copy of this order be given to the parties free of cost.

File be consigned to Record Room.

(Anil Kumar Bamba)           Member

(Adarsh Nain) Member

(Surinder Kumar Sharma) President