Punjab

Sangrur

CC/576/2014

Varsha - Complainant(s)

Versus

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

Shri R.K. Garg

23 Apr 2015

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.

                                                               

 

                                                Complaint No.    576

                                                Instituted on:      07.10.2014

                                                Decided on:       23.04.2015

 

Varsha D/o Adarsh Sehgal, resident of 1501, Sector 21, Panchkula, now wife of Shri Nishant Verma Resident of Guru Teg Bahadur Colony, Malerkotla, Distt. Sangrur.

                                                        ..Complainant

                                        Versus

National Insurance Company Ltd. Pili Kothi, Thandi Sarak, Malerkotla, District Sangrur.

                                                        ..Opposite party

 

For the complainant    :       Shri Rajesh Garg, Adv.

For opposite party      :       Shri Rohit Jain, Advocate.

 

 

Quorum:    Sukhpal Singh Gill, President

                K.C.Sharma, Member

                Sarita Garg, Member

 

 

Order by : Sukhpal Singh Gill, President.

 

1.             Smt.Varsha,  complainant (referred to as complainant in short) has preferred the present complaint against the opposite party (referred to as OP in short) on the ground that the complainant purchased a medical insurance policy from the OP in the year 2009 known as medi claim policy (family package) under cover note number G40400703540126 by paying the requisite premium of Rs.2082/- along with her husband. It is further averred that since 2009 the complainant has been continuously renewing her medi claim insurance policy from time to time.  It is further averred that at the time of issuance of the policy in question, the OP got conducted medical tests and also known about the previous history of the complainant as she met with an accident in the year 2008 and remained admitted in Alchemist Hospital. It is further averred that the policy in question was valid fro the period from 26.4.2009 to 25.4.2010 and thereafter she got renewed the policies renewed upto 25.4.2014 from time to time without any lapse.

 

2.             It is further averred that on 7.12.2011 the complainant got operated in Landmark Hospital and remained admitted for one day and was operated for removal of IMIL NAIL LT. SIDE UNDER SPINAL ANAESTHESIA and spent an amount of Rs.32,000/- for the purpose and thereafter the complainant approached the OP to repay the amount, but the OP did not pay the claim amount on the ground that the date of inception of the policy is from 2009 and the complainant got operated in the year 2008 was not covered under the policy and closed the claim file.  It is further averred that the complainant approached the OP so many times for payment of the claim, but all in vain.  Thus, alleging deficiency in service on the part of the OP, the complainant has prayed that the Op be directed to pay to the complainant an amount of Rs.32,000/- along with interest @ 12% per annum from the date of payment to the hospital  till realisation and further claimed compensation and litigation expenses.

 

3.             In reply, legal objections are taken up on the grounds that the complainant has no locus standi to file the present complaint, that the complainant has not come to the Forum with clean hands and that the complainant is not entitled to get any relief from the OP as the date of inception of the policy is from 2009 and the complainant got operated in the year 2008 was not covered under clause 4.1 of medi claim policy.  On merits, it is admitted that the complainant got medical insurance policy from the OP in the year 2009 by paying the requisite premium of Rs.2082/- and she is getting the policy renewed from time to time thereafter and lastly up to 25.4.2014. It is further stated that the OP wrote a letter to the complainant on 5.12.2013 in which it was mentioned that the date of inception of the policy is from 2008 and the complainant got operated in the year 2008 was not covered under the policy and closed the claim file of the complainant.  It has been denied that in the year 2009 when the complainant got the first policy from the OP at that time any medical tests of the complainant and her husband were got conducted by the OP prior to issuance of the policy and the past history of the complainant also inquire by the representative of the OP during which complainant disclosed all the facts.  It is further denied that on 7.12.2011 the complainant got operated in Landmark Hospital and remained admitted there one day for removal of IMIL NAIL LT. side under spinal anaesthesia and paid an amount of Rs.32,000/- to that hospital.  The remaining allegations of the complainant in the complaint have been denied in toto and any deficiency in service on the part of the OP has been denied.  It is further stated that the OP wrote letter dated 9.10.2013 to Shri Nishant Verma and made some inquiry, but he failed to reply the same.  The claim of the complainant was sent to Vipul Medcorp TPA Private Limited and as such after going through all the documents, policy and terms and conditions , the OP vide letter dated 5.12.2013 repudiated the claim of the complainant as ‘date of inception of policy is from 2009 and the complainant operated in 2008 and was not covered under the policy of the OP at that time. The current illness being outcome of the pre existing illness. The claim of the complainant is not payable and the same was repudiated under clause 4.1 of medi claim policy and closed the file.

 

4.             The learned counsel for the complainant has produced Ex.C-1 affidavit, Ex.C-2 to Ex.C-8 copies of policies of Oriental Insurance Company, Ex.C-9 to Ex.C-10 copies of letters, Ex.C-11 to Ex.C-15 copies of policies of National Insurance, Ex.C-16 to Ex.C-17 copies of letters, Ex.C-18 copies of treatment record of Landmark Hospital, Ex.C-19 medicine bills Ex.C-20 copies of discharge record and closed evidence. On the other hand, the learned counsel for the OP has produced Ex.OP-1 to Ex.OP-4 copies of policy, Ex.OP-5 copy of letter, Ex.OP-6 copy of medical certificate, Ex.OP-7 copy of email, Ex.OP-8 copy of policy, Ex.OP-9 copy of receipt, Ex.OP-10 to Ex.OP-11 copies of letters, Ex.OP-12 copy of letter, Ex.OP-13 copy of office note, Ex.OP-14 to Ex.OP-16 copies of letters, Ex.OP-17 affidavit, Ex.OP-18 copy of terms and conditions and closed evidence.

 

5.             We have very carefully perused the pleadings of the parties and heard the arguments of the learned counsel for the parties. In our opinion, the complaint merits dismissal, for these reasons.

 

6.             In the present case it is not in dispute that the complainant along with her husband took the medi claim policy from the year 2009 and got the same renewed from time to time till 25.4.2014 from the OP.  It is also not in dispute that earlier the complainant was insured with the Oriental Insurance Company Limited for the period from 7.11.2007 to 6.11.2008 and thereafter from 7.11.2008 to 6.11.2009 and in the year 2008 during the subsistence of the insurance policy with the Oriental Insurance Company Limited, the complainant met with an accident and took the claim from the Oriental Insurance Company Limited for that accident.  The complainant took treatment from Alchemist Hospital and as such claim was paid by the Oriental Insurance Co. Ltd.   Now, the case of the complainant is that by admitting herself in the hospital on 7.12.2011, she got operated in the Landmark Hospital for removal of IMIL NAIL LT. side under spinal anaesthesia and spent an amount of Rs.32,000/- on her treatment and lodged the claim with the OP i.e. National Insurance Company Limited.  But, the OP repudiated the claim of the complainant on the ground that the claim relates to the previous policy i.e. 2008 as the complainant met with an accident during the subsistence of the insurance policy with the Oriental Insurance Company Limited and got the claim from it for the loss suffered by her in the accident.  In the present case, it is an admitted fact on record by the parties that the claim of Rs.32,000/- relates to the previous year policy i.e. 2008 with the Oriental Insurance Company Limited, but the complainant preferred the present complaint against the OP instead of Oriental Insurance Company limited. It is worth mentioning here that the complainant should prefer the claim of Rs.32,000/- with the Oriental Insurance Company Limited.  Further clause 4.1 of the insurance policy clearly reveals that the company shall not be liable to make any payment under the policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of all diseases/injuries which are pre-existing when the cover incepts for the first time.  It is an admitted fact that the present claim of Rs.32,000/- arose during the first year of inception of the insurance policy. Further there is no explanation on record from the side of the complainant that why she did not lodge the insurance claim of Rs.32,000/- with the Oriental Insurance Company Limited as the claim arose from the accident of the year 2008.  Further there is nothing on record that the complainant ever apprised the OP about her pre existing disease i.e. accident of the year 2008 at the time of getting the insurance policy from the OP in the year 2009.  Under these circumstances, we find no deficiency in service on the part of the OP in repudiating the claim of the complainant under clause 4.1 of the insurance policy. 

 

7.             In view of our above discussion and circumstances of the case, we find no merit in the complaint and the same is dismissed. However, the parties are left to bear their own costs. A copy of this order be supplied to the parties free of cost. File be consigned to records.

                Pronounced.

                April 23, 2015.

                                                        (Sukhpal Singh Gill)

                                                           President

 

 

                                                              (K.C.Sharma)

                                                                Member

 

 

                                                                (Sarita Garg)

                                                                   Member