Delhi

North East

CC/31/2012

Smt. Anu Arora - Complainant(s)

Versus

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

11 Aug 2014

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM: NORTH-EAST

GOVT. OF NCT OF DELHI

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

 

Complaint Case No.31/12

 

CORAM:        Hon’ble President Sh. N.K. Goel

                        Hon’ble Member Sh. Nishat Ahmad Alvi

 

In the matter of:

Smt. Anu Arora

R/o F-268, 1^st Floor, New Rajinder Nagar,

New Delhi-60.                                                                                                 Complainant 

 

Versus

 

1. NATIONAL INSURANCE CO. LTD

808-809, 8^th Floor,

Kailash Building, 26, K.G. Marg,

New Delhi-110001     

  

2. NATIONAL INSURANCE CO. LTD

302, N.N. Mall, Near M2K Cinema,

Sector-3, Rohini

New Delhi-110085

 

3. GENINS INDIA TPA LTD.

B-127, Sector-2, Noida-201301                                       Opposite Parties

 

 

Order

 

                                                                                 DATE OF INSTITUTION: 13-01-2012

                                                                     DATE OF DECISION      : 31/01/2015

N.K. Goel, President :-

            According to the complainant she is a holder of the Mediclaim policy of the OP for the last 16 years covering herself and her husband and in continuation of policy No. 360400/48/08/8500001594 for the sum insured of Rs. 2,00,000/- for the period 7-1-09 to 6-1-10, she obtained continuous Parivar Mediclaim Policy bearing No. 360400/48/09/8500002164 for the sum insured of Rs. 2,00,000/- w.e.f. 7-1-10 to 6-1-11  from the OP ; that her husband Shri Inder Arora had a problem of severe chest pain on 11-02-10 and got admitted in CCU in DELHI HEART & LUNG INSTITUTE, New Delhi on the same day; that after doing tests and seeing the Angio Reports the treating doctors revealed triple vessel disease and started the treatment of the complainant but the condition of the patient was not under control and hence the complainant got him discharged by making a request vide provisional discharge summary dated 14-2-10; that during hospitalization of the husband of the complainant the hospital had sent a request for pre-authorization of cashless facility for the treatment to the OP insurance company’s 3^rd party administrator (OP3) but no response was received and hence the complainant was forced to pay the amount of the bill of Rs. 1,72,572/- to the hospital vide receipt No. 0910/43736 dated 11-2-10, 0910/43798 dated 11-2-10 and 0910/44267 dated 14-2-10 including hospitalization expenses; that thereafter she got her husband admitted to Indraprastha Apollo Hospital, New Delhi for further better treatment and higher management. It is, however, submitted that the OPs did not settle the claim amount of Rs. 1,72,572/- lodged by the complainant despite many requests and letters which amounts to deficiency in service. Hence, pleading deficiency in service on the part of OPs the complainant has filed the present complaint for directing the OPs to pay Rs. 3,23,572/- (Rs. 1,72,572/- towards hospitalization expenses of the husband of the complainant, Rs. 1,00,000/- for mental agony, pain and suffering, loss of business and Rs. 51,000/- towards litigation and other miscellaneous expenses) alongwith interest @ of Rs. 24% p.a.

            In their written statement OP1 and OP2 have denied that the complainant is the Mediclaim policy holder of these OP for the last 16 years. However, issuance of the Parivar policies for the period 7-1-09 to 6-1-10 and    7-1-10 to 6-2-11 is admitted. It is submitted that the pre-authorization request was received from DELHI HEART & LUNG INSTITUTE on 11-2-10 but the query was raised for the updated case summary; that it was informed by the DELHI HEART & LUNG INSTITUTE that the patient had been discharged on request from the hospital. It is submitted that in case sufficient information in the prescribed pre-authorization format is not given or in case of vague symptoms, where Mediclaim team of Genesis India TPA Ltd. is not sure of eligibility of coverage under the policy, due to inadequate medical information, pre-authorization for cashless can be denied; that the denial of cashless facility does not mean denial of treatment and does not prevent the insured from seeking necessary medical attention in hospital; that the claim can be considered for payment in accordance with the terms and conditions of policy; that the insured submitted the claim for reimbursement on 19-3-2010; that the claim documents included the documents of his hospitalization of Delhi Heart and Lung Institute; that after reviewing the submitted documents, it was found that the patient is a known case of CAD-old infra wall MI with hypertension since 1994; that as per the records available, it was a second year running policy; thus, the proximate cause of this claim fell under pre-existing disease; hence, the claim was recommended for repudiation as per exclusion clause 4.1.  Hence it is prayed that the complaint be dismissed.

In its reply OP3 has submitted that the complainant is not a consumer qua OP3 as there was no agreement between the complainant and OP3 to provide/perform any services/duty to the complainant by the OP3. The OP3 has also taken  similar pleas as taken by OP1 and OP2.

Complainant has filed a rejoinder to the WS  of OP1 and OP2. Thereafter, OP3 has been proceeded ex-parte vide order dated 10-10-12.

 Complainant has filed his affidavit in evidence. On the other hand, the affidavit of Sh.  P.C. Ghoswal, Senior Divisional Manager has been filed on behalf of OP1 and OP2. We have heard the counsel for the complainant. None has appeared to advance arguments on behalf of OP1 and OP2. We have gone through the file.

OPs have repudiated  the claim of the complainant by relying  on clause 4.1 of  the terms and conditions of the policy in question.  Clause 4.1 reads 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 National Insurance Company  only will be considered.

 Pre existing disease like Diabetes and Hypertension will be covered   from the inception of  the policy on payment of additional premium by the insured”.

Thus it is crystal clear that the said clause deals with existing   disease  by insured at the time of taking the mediclaim  policy for the first time .  Thus, if the insured or any of his/her family members covered under the policy is suffering from pre-existing disease  at the time of taking the policy for first time but he/she suppresses this fact  from the insurance  company  at the time of taking the policy and he/she gets himself/ herself admitted  to the hospital for treatment  of the pre-existing disease,  his/her claim for the treatment  charges shall not be  admissible  under clause 4.1 .  However, there must be cogent   evidence on the record to show that the insured was aware  of or had the knowledge of the pre- existing disease  at the time of taking the first policy.  The suppression of existing disease by the insured or the beneficiary of the policy must be   proved by the insurance company.  If the insurance claim has been rejected by the insurance company by taking the shelter of clause 4.1 on any other ground, the repudiation of claim  would not be justified .

In the present case, it is, no doubt, clear that the provisional discharge summary   of the husband  of the complainant ( copy filed on record) clearly proves that he was suffering  from Hypertension ,  had  the CAD  problem since 1994 and had also undergone P.T.C.A with  Stent   to RCA.  The  discharge summary also proves that the husband of the complainant  had got him discharged from  DELHI HEART & LUNG INSTITUTE  with diagnosis  “ Triple Vessel Disease” with an advise of early CABG.  These were undoubtedly  pre-existing diseases  with which the husband of the complainant was  suffering  at the time of taking the policy in question.  Copy of the report of OP3 ( Third Party Administrator) has been filed and marked as  Ex RW1/3 (exhibit  number is not put on the document).  Para 7 of the said report is relevant.  The same reads as under:-

“That the insured has submitted the claim in reimbursement on 19/03/2010.  The claim documents included the documents of his hospitalization of Delhi Heart & Lung Institute.  After reviewing the submitted documents, it was found  patient is a known case of CAD-old infra wall MI with hypertension since 1994.  As per the records available, it is a second year running policy.  The proximate  cause of this claim falls under pre-existing disease.  Hence, the claim was recommended for repudiation as per exclusion clause 4.1. (annexure B)” (Emphasis Supplied)

Thus  the said report does not show that the complainant or her husband  had suppressed the fact with regard to pre existing diseases,  that is, Hypertension  and Coronary Artery Disease (CAD) with which the complainant’s husband  was suffering at  the time of taking the policy  in question for the first time.  On the other hand,  the report clearly proves that the claim of the complainant had been repudiated  on the ground “ the proximate cause of this claim falls   under pre- existing  disease”.  What is  proximate cause  has remained  undefined in the policy in question  nor any such term or words  has/have  been used in clause 4.1.   

Thus we have reason to believe that the complainant had not suppressed any fact regarding the pre-existing diseases  of her husband at the time of taking the first policy.  No proposal form or any other document has  been filed on behalf of the OPs to proved to the contrary.

Thus, when the OPs had issued the Policies  in question knowing well that the husband of the complainant  who was a beneficiary of the policy was suffering from Hypertension and CAD, OPs  must be deemed to have modified  the term contained in clause 4.1 accordingly. OPs accepted the  premium  amounts of  the policy for two years.  When the complainant raised the mediclaim  in question OPs took the  shelter of clause 4.1 and repudiated the claim .  In our considered  opinion, the OPs committed deficiency in service in repudiating  the mediclaim in question.

In view of the above discussion,  we allow the complaint and direct OP1 & OP2 to pay  Rs. 1,72,572/-  towards claim in question along with  interest @  8%  p.a. from the  date of repudiation  of  the claim which, from the documents filed by the OPs and especially  the letter stated to be R3 written by OP3 after receiving the  notice from this  forum, is 19/03/2010 till date of realization,     Rs. 40000/- towards  mental pain and suffering  and Rs. 20000/- towards cost of litigation to the complainant within 30 days  from the date of receipt of the copy of this order. 

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 31/01/2015 ) 

 

(N.K. Goel)                                                                           (Nishat Ahmad Alvi)

President                                                                                       Member