DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II
Udyog Sadan, C-22 & 23, Qutub Institutional Area
(Behind Qutub Hotel), New Delhi-110016.
Case No.855/2009
Mrs. Usha Grover
Widow of Late Sh. Chander Prakash Grover
R/o H.No. 276, Patham Wara
Ward No.1, Sohna, Gurgaon (Haryana) ….Complainant
Versus
1. The Divisional Manager,
National Insurance Company Ltd.
Div. No.XXX, L-2, 1st Floor,
Green Park Extension,
New Delhi-110016
2. M/s Vipul Med Corp. TPA Pvt. Ltd.
515, Udyog Vihar, Phase-V,
Gurgaon, Haryana-122016 ……Opposite Parties
Date of Institution : 02.12.09 Date of Order : 26.03.16
Coram:
Sh. N.K. Goel, President
Ms. Naina Bakshi, Member
O R D E R
The case of the Complainant, in brief, is that she through her brother Sh. Rajesh Chaudhary had taken a mediclaim insurance policy No.354900/48/07/8500002882 for a period of one year from OPs from11.02.08 to midnight of 10.02.09 on 11.02.08 for an amount of Rs.2 lacs by paying a premium of Rs.6792/- and that too after due medical checkup by the OP. The OP had not informed any restrictions/exemptions regarding reimbursement of the mediclaim. She was diagnosed to be a case of Rheumatic Heart Disease (RHD) in the month of November, 2008. She was advised surgical procedure for replacement of mitral valve and she was admitted in Escorts Heart Institute and Research Centre for cardiac surgery and she remained in the hospital from 25.12.2008 to 09.01.09 where she was operated for replacement of the valve and she made the payment of Rs.4,40,069/-. Before the operation she was given the estimate for the surgery for Rs.2,80,000/- on 15.12.08. She approached the OP for cashless process for the surgery. She was advised to file a claim for reimbursement. She was discharged from the hospital on 09.01.09 and became entitled to reimbursement of the expenditure incurred on her operation limited to the extent of Rs.2 lacs. She completed all the formalities and forwarded the same to the OP No.2 on 17.01.09 for processing the claim for reimbursement. The said claim was rejected by the OP No.1 indicating therein the reason that the disease was contacted one year prior to the date of commencement of the policy on 11.02.08, hence the claim of the Complainant merited repudiation under clause 4.1 (pre-existing disease) of the policy. The Complainant has stated that if the disease was pre-existing, then how she was given the policy. The policy was also renewed for the period of one year from 11.02.09 to 10.02.10 for which the receipt towards the acknowledgment of the premium paid by her has been issued and appreciation letter dated 20.02.09 has also been issued by the OP No.2 (during the period) when the claim preferred by her during January 2009 was pending for finalization. The OP rejected the claim vide letter dated 19.03.09 under clause 4.1 of the terms and conditions of the policy. The Complainant has further stated that she had taken the policy on 11.02.08 and was diagnosed the disease in the month of Nov. 2008 and was hospitalized from 25.12.08 to Jan. 2009 and hence it amounts to unfair trade practice as well as deficiency in service on the part of OPs. Complainant has prayed as under:-
- Direct the OP No.1 to reimburse the payment of Rs. 2 lacs being the insured amount under the policy alongwith 12% interest from the date of filing of this complaint till its realization.
- Direct the OPs to pay a sum of Rs.2,50,000/-towards compensation and damages for causing mental agony and harassment and humiliation, emotion suffering, physical and mental discomfort, torture/ huge financial losses on account of expenditure incurred on her surgical procedure.
- Direct the OPs to pay Rs.11000/- as the legal expenses.
OP No.1 in the written statement has stated that the Complainant played a fraud upon the OP No.1 by not disclosing that she was suffering from rheumatic heart disease since childhood and was also suffering from this ailment at the time of taking the mediclaim policy bearing No. 354900/48/07/85/00002882. The opinion report dated 24.06.09 clearly states that the insured was suffering from rheumatic heart disease which is a childhood disease & thus she must have been diagnosed with this ailment earlier and therefore by not disclosing this fact at the time of taking up the said policy, the complainant had played a fraud on the OPs. Therefore, OP No. 1 has rightly rejected and repudiated the claim. The policy cover given by OP No.1 was according to the terms and conditions which were well accepted by the Complainant and in the knowledge of the insured. As per exclusion clause 4.1 (pre-existing disease) “the company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of all diseases/injures which are pre-existing when the cover incepts for the first time.” The OP No.1 rightly repudiated the claim of the Complainant. OP No.1 has prayed for dismissal of the complaint.
OP No.2 has been proceeded exparte vide order dated 12.05.11 passed by our predecessors.
Complainant has filed rejoinder to the written statement of OP No.1.
Complainant has filed her affidavit in evidence while affidavit of Sh. J.S. Joon, Divisional Manager has been filed in evidence on behalf of OP No.1.
Written arguments have been filed on behalf of the Complainant and OP No.1.
We have heard the arguments on behalf of the parties and have also gone through the file very carefully.
It is not in dispute that the Complainant had obtained a mediclaim insurance policy No.354900/48/07/8500002882 from OP No.1, covering the period 11.02.08 to midnight 10.02.09 on 11.02.08 by paying a premium of Rs.6792/-. According to the OP No. 1, request for cashless hospitalization was denied as per clause 4.1 of the policy. It is undisputed that the Complainant had paid the full bill amount of Rs.440069/- to the Escort Hospital and requested the OP No.1 to reimburse the policy amount to the extent of Rs.2 lakhs. The OP No.1 had rejected/repudiated the claim as per exclusion clause 4.1 of the policy as stated hereinabove.
In our considered view, the repudiation of the claim made by the complainant by the OPs was not at all justified for the following reasons:
- The averments made by the complainant that before issuing the policy in question to her, she had been made to undergo various pathological and lab tests have not been denied by the OPs. Thus, it stands proved that before issuing the policy in question, the OPs had got the pathological and lab tests of the complainant done. The OPs have not filed the copies of these reports. Therefore, we draw an adverse influence against the OPs.
- The OPs have not filed any medical literature on the record to show that rheumatic heart disease is a childhood disease and the complainant was suffering with the said disease at the time of issuing the policy in question to her. It has relied on opinion/report dated 24.6.2009 but copy of no such opinion/report has been filed on the record. Therefore, we again draw an adverse presumption against the OPs.
- Copy of discharge summary of the complainant has been placed on the record which we mark as Mark AA for the purposes of identification. The history of the complainant has been prescribed as hereunder:
“HISTORY:
History of Presenting Illness: Patient is normotensive, non diabetic and has positive family history of ischemic heart disease. She presented with complaint of breathlessness for last 1 year. She was admitted to the hospital for evaluation and further management.”
Thus, the complainant had gone to the Escort Hospital with complaint of breathlessness for last 1 year but it does not show that she was suffering from rheumatic heart disease. In other words, there is absolutely no evidence on the record to prove that the complainant was suffering with rheumatic heart disease since prior to the date of issuance of the policy in question to her.
Therefore, we hold the OPs guilty of deficiency in service. Accordingly, we allow the complaint and direct the OP-1 to pay Rs.2 lacs alongwith interest @ 6% per annum from the date filing of the complaint till the date of realization, Rs. 25,000/- towards mental pain and agony and Rs. 5500/- towards litigation expenses to the complainant within 30 days of receipt of copy of this order failing which OP No. 1 shall become liable to pay the amount of Rs. 2 Lacs along with interest @ 12% per annum from the date of filing of the complaint till the date of realization.
Let a copy of this order be sent to the parties as per regulation 21 of the Consumer Protection Regulations. Thereafter file be consigned to record room.
Announced on 26.03.16.
(NAINA BAKSHI) (N.K. GOEL) MEMBER PRESIDENT
Case No. 855/09
26.3.2016
Present – None.
Vide our separate order of even date pronounced, the complaint is allowed. OP-1 is directed to pay Rs.2 lacs alongwith interest @ 6% per annum from the date filing of the complaint till the date of realization, Rs. 25,000/- towards mental pain and agony and Rs. 5500/- towards litigation expenses to the complainant within 30 days of receipt of copy of this order failing which OP No. 1 shall become liable to pay the amount of Rs. 2 Lacs along with interest @ 12% per annum from the date of filing of the complaint till the date of realization. Let the file be consigned to record room.
(NAINA BAKSHI) (N.K. GOEL) MEMBER PRESIDENT
