Before the District Consumer Disputes Redressal Forum, Rohtak.

                                                          Complaint No. : 361.

                                                          Instituted on     : 10.10.2014.

                                                          Decided on       : 10.03.2016.

 Sh. Basant Jain s/o Kesri Lal Jain, r/o Gali Old Post Office Lane, Jhajjar Road, Rohtak.

                                                          ………..Complainant.

                             Vs.

Manager, National Insurance Company Limited, Narain Shopping Complex, Civil Road, Rohtak-124001.

                                                     ……….Opposite party.

          COMPLAINT U/S 12 OF CONSUMER PROTECTION ACT,1986.

BEFORE:  SH.JOGINDER KUMAR JAKHAR, PRESIDENT.

                   MS. KOMAL KHANNA, MEMBER.

                   SH.VED PAL, MEMBER.

Present:       Sh. Rinku Jangra, Advocate for the complainant.

                   Sh.O.P.Punia, Advocate for the opposite parties.

                                      ORDER

SH. JOGINDER KUMAR JAKHAR, PRESIDENT :

1.                          The present complaint has been filed by the complainant with the averments that he alongwith his wife was insured under the National Mediclaim policy bearing registration no. 421600/48/14/8500000039 and as per the policy the complainant and his wife were entitled to get 100% value on the expenses occurred in treatment in case of accident, operation, hospitalization etc. It is averred that the sum insured under the policy was Rs.400000/-. It is averred that in April 2014, the complainant’s wife was suffering from leg pain and diseases and therefore she was admitted in Medanta Hospital, Gurgaon and doctor of the said hospital suggested the complainant’s wife for total knee replacement(Bilateral) and the complainant’s wife was admitted in said hospital on 30.04.2014 and remained there upto 07.05.2014 where her legs were operated and the complainant had incurred the expenses of Rs.481682/- on the treatment. It is averred that besides that complainant has also incurred Rs.20000/- on traveling expenses and guest house expenses of Rs.30000/-. The complainant was discharged on 07.05.2014 and after that as per the advise of doctor, complainant took regular therapies from physiotherapist and incurred expenses of Rs.50000/- in the said treatment. It is averred that complainant informed the opposite party after getting admission in the hospital. The opposite party has given the amount of Rs.217500/-under cashless scheme to the complainant whereas the complainant was entitled to take Rs.400000/-for total sum insured and Rs.83750/- for C.Bonus.  It is averred that complainant requested the opposite party to pay the full insured amount but the opposite party make false excuses to delay the genuine claim of the complainant and on 24.09.2014 sent a letter to the complainant submitting therein that the claim of the complainant is not admissible. It is averred that the act of opposite party is illegal and amounts to deficiency in service. As such it is prayed that opposite party may kindly be directed to pay the amount of claim of Rs.266250/- alongwith interest, compensation and litigation expenses to the complainant.

2.                          On notice opposite party appeared and filed its separate written reply submitting therein that the case of the patient Gyan Bala has been settled as per terms and conditions of the policy. As per the conditions the increase in the premium of the mediclaim policy is applicable after the completion of  4 years. It is averred that the patient should obtained the pre sanctioned for such types of diseases which is not so serious so the complainant patient get the benefit of the package policy which is available in the company. It is averred that there is tie up from the Medanta Medicity Global Health Pvt. Ltd. It is wrong that the complainant sent Rs.481682/- in the hospital. It is averred that the complainant was entitled for Rs.208000/- as per the terms and conditions of the policy which was paid to hospital by TPA. It is averred that complainant is not entitled for Rs.483750/- and there is no deficiency in service on the part of the answering opposite party. All the other contents of the complaint were stated to be wrong and denied. Opposite party prayed for dismissal of the complaint with costs.

3.                          Both the parties led evidence in support of their case.

4.                          Complainant in his evidence has tendered affidavit Ex.CW1/A, documents Ex.C1 to Ex.C14 and has closed his evidence. On the other hand ld. Counsel for the opposite party tendered affidavit Ex.R1, documents Ex.R2 to Ex.R16 and has closed his evidence.

5.                          We have heard ld. counsel for the parties and have gone through the material aspects of the case carefully.

6.                          In the present case it is not disputed that as per policy document Ex.C14 the complainant along with his wife were insured with the opposite party under the policy no.421600/48/13/8500000034 under the hospitalization benefit policy for the period from 25.04.2013 to 24.04.2014 and the same was in continuation of the policy Ex.C10 to Ex.C13 for the period from 25.04.2009 to 24.04.2010, 25.04.2010 to 24.04.2011, 25.04.2011 to 24.04.2012 and 25.04.2012 to 24.04.2013 respectively.  It is also observed that as per bills/receipts Ex.C2 to Ex.C3 issued by Medanta Hospital, the complainant had spent a sum of Rs.481682/- on the  treatment of his wife Smt. Gyan Bala who was also insured with the opposite party. After the treatment complainant filed the claim with the opposite party but the opposite party has paid only an amount of Rs.217500/- to the complainant. The contention of the complainant is that the he was entitled to get the remaining amount of Rs.266250/- but the same was repudiated by the opposite party vide its letter Ex.R3 on the ground that “Sum insured+ CB amount already exhausted”. Hence the claim is not admissible.

7.                          After going through the file and hearing the parties it is observed that as per the policy Ex.C14 the sum insured under the policy is Rs.325000 + C.B Amount Rs.73750/- whereas as per letter Ex.R4 the claim has been settled on SI 1.5 LACS + CB 58000/-.  The contention of ld. Counsel for the opposite party is that as per terms and conditions of the policy, the complainant/patient should obtain pre-sanction where the disease is not so serious which required immediate medicare. The complainant failed to obtain the pre-sanction from the answering opposite party because the concerned hospital i.e. Medanta Medicity is on the penal of the company and there is a treatment package for the mediclaim policy. It is further contended that as per the terms and conditions of the policy Ex.R7, “Treatment of Joint replacement due to degenerative conditions, Age related osteoarthritis and osteoporosis are not payable for the first four years of operation of the policy. In this regard it is observed that firstly the alleged terms and conditions of the policy have not been supplied to the complainant. Moreover  in the present case the policy Ex.C14 is in continuation of previous policies i.e. Ex.C10 to Ex.C13. Hence the exclusion clause 4.3 of the policy is not applicable to the facts and circumstances of the case. In this regard we have placed reliance upon the law cited in 2015(1)CLT591 titled as Star Health and Allied Vs. Asha & Others, whereby it is held that: “Insurance policy-Exclusion clause-Not explained to insured when cover note was issued-Insurance company cannot derive any benefit from exclusion clause”. We have also placed reliance upon the law cited in upon 2013(1)CLT 589 titled as New India Asurance Co. Ltd. Vs. Pabbati Sridevi & Others whereby Hon’ble National Commission has held that: “Terms and conditions therein, not communicated to the insured-Whether can be used by Insurance Company-No-Held that the terms and conditions were never issued to the insured-Policy is in the nature of standard, printed documents. There is nothing to show that its contents were part of the policy document issued to the insured-Terms and conditions in insurance policy cannot be rely upon by insurance company” In view of the aforesaid law which are fully applicable on the facts and circumstances of the case it is observed that the complainant is entitled for the full claim amount under the policy.

8.                          In view of the facts and circumstances of the case it is observed that as per policy Ex.C14 the sum insured is Rs.325000/- + CB is Rs.73750/- i.e. total Rs.398750/-. But the opposite party has only paid the amount of Rs.217500/- to the complainant. As such it is directed that opposite party shall pay the remaining amount of Rs.181250/-(Rupees one lac eighty one thousand two hundred fifty only) under the policy no.421600/48/13/8500000034 alongwith interest @ 9% p.a from the date of filing the present complaint i.e. 10.10.2014 till its actual realization, other benefits under the policy, if any and shall also pay an amount of Rs.3000/-(Rupees three thousand only) as litigation expenses to the complainant maximum within one month from the date of decision failing which the awarded amount shall carry interest @ 12% p.a. from the date of decision. Complaint is allowed accordingly.

9.                          Copy of this order be supplied to both the parties free of costs.      File be consigned to the record room after due compliance.

Announced in open court:

10.03.2016.

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                                                          Joginder Kumar Jakhar, President

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                                                          Komal Khanna, Member.

                                                          …………………………

                                                          Ved Pal, Member.