Haryana

Ambala

CC/315/2019

Sh Kunal Aggarwal - Complainant(s)

Versus

National Insurance Co Ltd - Opp.Party(s)

Rohit Gupta

07 Jul 2022

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, AMBALA.

 

                                                                      Complaint case no.         :     315 of 2019

                                                          Date of Institution           :     30.09.2019

                                                          Date of decision     :     07.07.2022.

         

Shri Kunal Aggarwal son of Shri Anil Aggarwal, resident of H.No.17-A, Shastri Nagar, near Dayal Bagh Chowk, Mahesh Nagar, Ambala Cantt.

                                                                             ……. Complainant.

                                      Versus

1.       National Insurance Company Divisional Office, 106, Railway Road, Ambala Cantt., through its Divisional Manager.

2.       Vipul Medcorp, SCI-98, Industrial Area, Phase II, near Bank of Baroda, Chandigarh (U.T).

 

                                                                    ….…. Opposite Parties.

Before:        Smt. Neena Sandhu, President.

                   Smt. Ruby Sharma, Member.

Shri Vinod Kumar Sharma, Member.

 

Present:       Shri Rohit Gupta, Advocate, counsel for the complainant.

Shri Mohinder Bindal, Advocate, counsel for the OP No.1.

OP No.2 already ex parte.  

 

Order:        Smt. Neena Sandhu, President.

1.                Complainant has filed this complaint under Section 12 of the Consumer Protection Act, 1986 (hereinafter referred to as ‘the Act’) against the Opposite Parties (hereinafter referred to as ‘OPs’) praying for issuance of following directions to them:-

1. To pay the claim of Rs.40,566/-.
2. To pay Rs.50,000/-, as compensation for the mental agony and physical harassment suffered by the complainant.
3. To pay Rs.11,000/- as counsel fee

OR

Any other relief which this Hon’ble Commission may deem fit.                                

                    

2.                Brief facts of the case are that the complainant had taken a Health claim Policy bearing No.420400501810000012, from OP No.1, for the period from 12.04.2018 to 11.04.2019, for sum assured of Rs.1,00,000/-. In the month of August, 2018, complainant suddenly had stomach pain and on checking by the Doctor of Shri Sai Hospital, Ambala Cantt., it was diagnosed that he was suffering from Hernia and the said doctor advised him for immediate operation. Complainant got admitted in the said hospital on 26.08.2018 and Hernioplasty on left side Mesh was done on 27.08.2018 and he was discharged from the Hospital on 29.08.2018 and he incurred Rs.37,096/-, on his treatment. On 21.02.2019, complainant again had a pain in his stomach and immediately he went to the Prakriya Hospital, for treatment. There doctor diagnosed that there is stone in the kidney. Complainant paid Rs.3,470/-, to the said hospital, for medicines and clinical tests. In total complainant spent Rs.40,566/-, on his medical treatment. Complainant lodged the claim with the OP No.1 and also completed all the requisite formalities but the OPs rejected his claim on the ground of delay. Complainant served a legal notice dated 06.09.2019, upon the OPs, whereby requested them for payment of the claim amount, but the OPs neither replied the said notice nor paid the claim amount. Hence, the present complaint. 

3.                Upon notice, OP No.1 appeared and filed written version, raised preliminary objections with regard to maintainability, cause of action, not come with clean hands and suppressed the material facts etc. On merits, it is stated that the insurance policy for the period from 12.04.2018 to 11.04.2019, for sum assured of Rs.1,00,000/-, subject to certain terms and conditions, which includes certain exclusion and waiting periods with regard to certain treatments which were to be covered after specific waiting period. As a matter of fact claim of the complainant against the treatment of the complainant in Shri Sai Hospital, Ambala Cantt., from 26.08.2018 to 29.08.2018 was duly entertained in due course without going into the maintainability aspect of the claim. The entire case with all set of papers was duly gone through by the qualified team of doctors i.e M/s Vipul Medcorp insurance TPA Pvt. Ltd., the duly authorized representative of the answering OP. In the present case, claim was lodged with the IRDA approved agency M/s Vipul Medcorp insurance TPA Pvt. Ltd., i.e Op No.2. Since it was the 1^st year of the Health Inusrance Policy wherein as per Section 4.3 of the condition of the policy, the treatment of with regard to Hernia falls under exclusion for specific two years waiting period and after pursuing the treatment record, the said claim was denied and rejected by the said TPA as per terms and conditions of the policy. In the light of the recommendations of the said TPA, the claim was finally considered by the competent authority and the same was repudiated according to the terms of policy. Even, the claim of the complainant was not payable as per law and terms of policy because of inordinate and unexplained delay of 218 days, in intimation of claim to the insurance company and delay of 247 days in submission of the claim paper. Vide letter dated 30.08.2019, answering OP duly informed the complainant about the fate of his claim. Complainant in order to put undue pressure has filed this false complaint against the answering OP and same may be dismissed with special costs.  

4.       Upon notice, none has appeared on behalf of the OP No.2 before this Commission, therefore, it was proceeded against ex-parte vide order dated 14.11.2019.

5.                Learned counsel for the complainant tendered affidavit of complainant as Annexure C-A along with documents Annexure C-1 to C-43 and closed the evidence of the complainant. On the other hand, learned counsel for the OP No.1 tendered affidavit of Shri S.C.Dass, authorized Signatory, National Insurance Company Limited, Divisional Office, Ambala Cantt., as Annexure OPA alongwith documents Annexure OP-1 to OP-6 and closed the evidence on behalf of OP No.1.

6.                We have heard the learned counsel for the complainant and learned counsel for the OP No.1 and have also gone through the record very carefully.

7.                 From the perusal of Schedule of Mediclaim policy, Annexure C-4/OP-4, it is evident that complainant was duly insured with the National Insurance Company i.e OP No.1, for the period from 12.04.2018 to 11.04.2019, for Sum Insured of Rs.1,00,000/-. From the discharge report issued by Shri Sai Hospital, Annexure C-23, it is clear that complainant was admitted in the said hospital on 26.08.2018 and left sided Mesh Hernioplasty done under SA on 27.08.2018 and was discharged on 29.08.2018. The learned counsel for the complainant has contended that complainant spent Rs.37,096/-, for treatment of Hernia and paid Rs.3,470/-, to Parkriya Hospital, for treatment of kidney stone, as is evident from the medical bills, Annexure C-24 to C-35. However, vide letter dated 30.08.2019, OPs repudiated the genuine claim of the complainant.

8.                On the contrary, the learned counsel for the OPs has contended that the OP No.1 has rightly repudiated the claim as there was delay of 218 days in intimating the insurance company and delay of 247 days in submission of claim documents with it and complainant had undergone surgery for Left Ingunal Harnia Left Sided Mesh Hernioplasty, within four months from the date of inception of the policy, thus claim is not payable, as per clause No.4.3, Specific Waiting Period of the terms and conditions of the policy Annexure OP-4, which reads as under:-

4.3 Specific Waiting period

Disease/treatments listed below are subject to waiting periods as follows.

i. One year waiting period

a. Benign ENT disorders                             d. Mastoidectomy

b. Tonsillectomy                                         e. Tympanoplasty

c. Adenoidectomy

ii. Two year waiting period

a. Cataract                                          m. Diabetes and related complications as                                                           mentioned in 4.1

b. Benign Prostatic hypertrophy         n. Calculus diseases

c. Hernia                                            o. Surgery of gall bladder and bile duct                                                             excluding malignancy

d. Hydocele                                       p. Surgery of genito-urinary system                                                                  excluding malignancy

e. Fissure/Fistula in anus                    q. Surgery for prolapsed intervertebral                                                               disc unless arising from accident

f. Piles (Haemorrhoids)                      r. Surgery of varicose vein

g. Sinusitis and related disorders        s. Hysterectomy

h. Polycystic ovarian disease             

i. Non-inflective arthritis

j. Pilonidal sinus

k. Gout and Rheumatism

l. Hypertension and related                                                                  complications as mentioned in 4.1

iii.      Four years waiting period

          a. Treatment for joint replacement unless arising from accident

          b. Osteoarthritis and osteoporosis      

9.                From the record it is borne out that the complainant was operated upon for Hernia, within four months from the date of inception of the policy, thus the case of the complainant would fall within the exclusion clause No.4.3 (ii), of the policy, reproduced above and as such, he is not entitled to get any claim. Be that as it may, the complaint filed by the complainant is devoid of merits, consequently, we dismiss the same. Parties are left to bear their own costs. Certified copy of the order be supplied to the parties concerned, forthwith, free of cost as permissible under Rules. File be indexed and consigned to the Record Room.

Announced on: 07.07.2022.

 

 

          (Vinod Kumar Sharma)  (Ruby Sharma)               (Neena Sandhu)

              Member                         Member                       President