District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No. 110/2021.
Date of Institution:25.02.2021.
Date of Order: 31.03.2023.
Dharampal Dudeja R/o H.No. A-121, Sainik Colony, Sector-49, Faridabad.
…….Complainant……..
Versus
1. National Insurance company, 3, Middleton Street, Kolkata – 700 071 (through its authorized person).
Also at:
National Insurance Company, SCO 96, First floor, Sector-16 Market Faridabad.
Also at:
National Insurance Company, 5C-1 Near Neelam Chowk, NIT, Faridabad, Sector-16 Market, Faridabad (through Branch Manager/authorized person)
2. Safeway Insurance TPA Pvt. Ltd., 815, Vishwa Sadan, Distt. Center, Janakpuri, Delhi – 58 (through its Director/Authorized person)
…Opposite parties.
Complaint under section-12 of Consumer Protection Act, 1986
Now amended Section 34 of Consumer protection Act 2019.
BEFORE: Amit Arora……………..President
Mukesh Sharma…………Member.
Indira Bhadana………….Member.
PRESENT: Sh. Naresh Madan, counsel for the complainant.
Sh. Neeraj Kumar Gupta, counsel for opposite party No.1.
Opposite party No.2 ex-parte vide order dated 10.08.2021.
ORDER:
The facts in brief of the complaint are that the complainant namely Dharampal Dudeja R/o H.No. A-121, Sainik Colony, Sector-49, fAridabad had been availing National Parivar Mediclaim policy – a floater policy vide policy No.361500501710002826 for the year 2017-18 which had been timely renewed every year, The initial date of proposal for the policy was 5.12.2010 and there had been no break in the policy and the same had been timely renewed in each subsequent year. For the aforesaid policy, sum insured was enhanced from Rs.3,00,000/- only to rs.Rs.5,00,000/- for the year 2014-15 which remained same in the policy for the year 2015-16 also. The complainant had further enhanced insured sum of Rs.10,00,000/- for the year 2016-17 vide policy NO. 361500/48/16/8500003315 and continued in 2017-18 vide policy No. 361500501710002826. While enhancing the insured amount, the complainant was handed over a web down loaded copy of terms of policy namely prospectus. The wife of the complainant namely Aarti Dudeja fell sick and as such, she availed benefits of mediclaim insurance, however, the complainant was then refused the insurance benefit – for her wife Aarti Dedeja – beyond the amount of Rs.4,00,000/- only for the period 2016-17/2017-18. Vipul Medicorp was earlier a third party administrator who had refused to approve and disburse insurance amount beyond Rs.4,00,000/- on untenable grounds that the waiting period was 4 years, that such a ground was an absolute misrepresentation by opposite parties in order to evade the lawful claim of insured sum by the complainant. Accordingly, a complaint NO.
47/2019 against No. 47/2019 against before this Commission was instituted by the complainant herein which was decided in favour of the complainant vide judgement and order dated 29.10.2019. In the aforesaid earlier complaint, complainant inter alia relied on clause 4.3(ii) (m), it clearly shows that waiting period for diabetes related complications as mentioned in Clause 4.1 shall be 2 years only. It was also pleaded by the complainant that in any case, the aforesaid policy had been continued since 2010 without any break and without any delayed payments, and as such, condition of waiting period did not apply to the case of the complainant. The said issues were decided in favour of the complainant in that case. The opposite party insurance company even had passed further claim i.e. in next renewal year of previous complaint of Rs.6 lacs in accordance with the enhanced insurance amount of Rs.10 lacs, only as this Hon’ble Forum and recorded clear finding that waiting period as per exclusion clause had elapses. Now the complainant again had raised claim dated 28.12.2019 and 9th Jan.2020 for the subsequent expenses incurred on the insured to the tune of Rs.12,99,571/- out of which only Rs.5,00,000/- only had been reimbursed by the respondents whereas Rs.7,99,571/- were withheld by the opposite parties. This time, Third Party Administrator was opposite party No.2 herein above and very strangely, the opposite parties, despite having passed the previous claims based on enhanced sum insured, again repudiated the claim beyond amount of Rs.5,00,000/- only on the same grounds which were taken thereby in previous complaint. The opposite party had, however, again raised the same ground of “exclusion clause period” and “pre existing decease” for subsequent claim” made by the complainant whereas the Hon’ble Commission had already decided this issue in favour of the complainant in earlier complaint and had allowed the said complaint. The collusion between opposite parties would be clear from the communication between complainant and
opposite party No.2 from the fact that they had again taken the same ground of waiting period of 4 years for pre-existing (contrary to the terms of policy which states 2 years time for the disease in question as per clause 4.2) which this forum had already decided in favour of the DH-complainant. The aforesaid act of opposite parties amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite parties to:
a) pay interest u upon the declined amount of claim from the date of repudiation till its date of realization @ 12% p.a.
b) pay Rs. 25,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 25,000 /-as litigation expenses.
2. Opposite party No.1 put in appearance through counsel and filed written statement wherein Opposite party No.1 refuted claim of the complainant and submitted that the complainant had no locus standi to file the present complaint. The complainant extended the policy amount time to time, but at the time when the complainant was admitted in hospital he was entitled for the policy amount of Rs.5,00,000/-. The proposer Mr. Dharampal Dudeja had been issued National Parivar Mediclaim policy and the opposite party are guided by policy terms and conditions of this policy. Policy clause No. 5.15 states as under:
Clause 5.15 Enhancement of sum insured:
Sum insured can be enhanced only at the time of renewal;.
Sum insured may be enhanced to the next slab subject to the discretion of the company be enhanced to the next slab subject to the discretion of the company. For the incremental portion of the sum insured, the waiting periods and conditions
as mentioned in exclusion 4.1, 4.2, 4.3 shall apply. Coverage on enhanced sum insured shall be available after the completion of waiting periods. The opposite party never denied the claim of the complainant, hence the claim of the complainant was pre mature and the opposite party had already paid payment of Rs.5,00,000./- to the complainant. Opposite party No. 1 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. Case had been called several times since morning but none appeared on behalf of opposite party No.2 Hence, opposite party No.2 was proceeded against exparte vide order dated 10.08.2021.
4. The parties led evidence in support of their respective versions.
5. We have heard learned counsel for the parties and have gone through the record on the file.
6. In this case the complaint was filed by the complainant against opposite parties–National Insurance Company & anr. with the prayer to: a) pay interest u upon the declined amount of claim from the date of repudiation till its date of realization @ 12% p.a. b) pay Rs. 25,000/- as compensation for causing mental agony and harassment . c) pay Rs. 25,000 /-as litigation expenses.
To establish his case the complainant has led in his evidence, Ex.C-1 –Terms & conditions of Parivar Mediclaim for Family, Ex.C-2 - policy valid from 06.12.2019 to 05.12.2020, Ex.C-3 – order dated 29.10.2019 passed by the DCDRF, Faridabad, Ex.C-5 – letter dated 18.01.2020, Ex.C-6 – email dated 27.05.2020.
On the other hand counsel for the opposite party No.1 strongly agitated and opposed. As per the evidence of the opposite party No.1 Ex.RW1/A
– affidavit of Shri Lakhan Pal, Assistant Manager, National Insurance co. Ltd., Faridabad, Ex.R-1 – insurance policy valid from 06.12.2019 to 05.12.2020.
7. During the course of arguments counsel for the complainant has filed an application for summoning the case file and placing on record the written arguments alongwith the following authorities:
i) M/s. Gokulam Farma and Estates Pvt. Ltd. And another Vs. Sri Muneer Pasha decided on 6.8.2007 passed by the Hon’ble High Court of Karnataka. 2007 0 Supreme(Kar) 481.
ii) National Insurance Co. Ltd. Vs. J.P.Singh decided on 19.12.2008 passed by the Hon’ble State Consumer Disputes Redressal Commission.
iii) Kawaljit Singh Vs. National Insurance Company Ltd. Decided on August 14,2019 in Civil Appeal No. 6255 of 2019 passed by the Hon’ble Supreme Court of India.
The counsel for the complainant also stated at Bar that the same case was decided by the Hon’ble Consumer Disputes Redressal Commission, in CC No. 47/2019 decided on 2910.2019 vide Ex.,C-3. Now this complaint bearing No. 110/2021 filed before this Commission with the same issue and with the same cause of action and also stated that the complainant has more different policies from the same company and argued at length once the decision has already been given in favour of the complainant , the question for denial the claim of the complainant in this case does not arise. On the other hand Shri Neeraj Gupta , counsel for opposite party admitted this fact that there are other polices of the same complainant and he can also mediclaim through different policies also.
7. After going through the evidence led by both the parties, the Commission is of the opinion that the complaint is allowed, Opposite parties are directed to process the claim of the complainant within 30 days from the date of receipt of the copy of order and pay the due amount to the complainant along with interest @ 6% p.a. from the date of filing of complaint till its realization. The opposite parties are also directed to pay Rs.3300/- as compensation on account of mental tension, agony and harassment alongwith Rs.2200/- as litigation expenses to the complainant. Copy of this order be given to the parties concerned free of costs and file be consigned to record room.
Announced on: 31.03.2023 (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
(Indira Bhadana)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
