BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR.

Consumer Complaint No. 530 of 2015

Date of Institution: 25.8.2015

  Date of Decision: 17.5.2016

Raman Kumar Mehta resident of H.No. 1083, Main Bazar, Katra Khazana, Amritsar

Complainant

Versus

National Insurance Company Ltd. Above Allahabad Bank, Opp.S.S.P. Residence, The Mall,Amritsar through its Branch Manager

Opposite Party

Complaint under section 12/13 of Consumer Protection Act, 1986

Present:    For the Complainant                  :         Sh.Updip Singh,Advocate

For the Opposite Party     :         Sh.S.K.Davessar,Advocate

Coram

Sh.S.S.Panesar, President

Ms.Kulwant Kaur Bajwa, Member

Sh.Anoop Sharma,Member

Order dictated by:

Sh.S.S. Panesar, President.

1.       Raman Kumar Mehta,complainant has brought the instant complaint under section 12 and 13 of  the Consumer Protection Act, 1986  on the allegations that  complainant is subscriber of mediclaim policy issued by the opposite party since the year 2012. The complainant on 16.1.2015 in continuation  of the previous policy purchased policy No. 401208/48/13/8500000988 operative w.e.f. 17.1.2014 uptil 16.1.2015 against premium of Rs. 3616/- for a mediclaim cover upto Rs.2,50,000/-. The said policy was issued by Bank of India , Branch Majith Mandi, Amritsar being agent of opposite parties where complainant is having his account.  While the said policy was still operative, complainant had heart problem for which he was immediately taken to Fortis Escorts Hospital, Amritsar & Angioplasty was performed upon him. The complainant remained admitted in the hospital upto 6.11.2014. During hospitalization,  the complainant spent Rs. 2,16,454/- in total for which claim was lodged with the opposite party which was repudiated vide letter dated 12.12.2014 arbitrarily on the ground that “KNOWN CASE OF CAD SINCE 2003”. Although the complainant had a episode of CAD in the year 2003, however, the same was completely cured after Angioplasty. The complainant was not symptomatic of any heart problem since then and even TREAD MILL TEST/ECHO report of the complainant dated 7.3.2009 gave findings of “NORMAL STRESS TEST’ (NEGATIVE FOR REVERSIBLE MYOACRDIAL ISCHEAEMIA). The complainant issued letter to the General Manager (Grievance) of opposite party Insurance company on 20.12.2014 but vide letter dated 3.2.2015, the branch manager of opposite parties again informed  the complainant that as informed earlier, the claim is not payable. The complainant further filed representation  to Grievance Redressal Cell of IRDA and then to Insurance Ombudsman at Chandigarh , who vide order dated 15.5.2015, dismissed the representation of the complainant arbitrarily . Infact, during the period  of 2003, when the complainant was treated effectively for cardiac problem, till Nov. 2011 when the fresh episode occurred, the complainant was not having any heart problem. Even in the year 2009, when in routine investigations, stress Echo test was performed, no abnormality was found in cardiac condition of the complainant . None of the authorities including TPA  of opposite party considered the report  of Stress Echo while discarding claim of the complainant on arbitrary ground of “pre-existing disease”. Moreover, the problem  which the complainant faced in the year 2014 was a fresh lesion and had got no correlation with the cardiac condition or treatment obtained in the year 2003 as the ailment of year 2003 stood fully cured. For the above mentioned deficient acts of opposite party for not making payment of genuine claim, complainant    is suffering harassment, mental agony and financial loss for which the opposite parties are liable to compensate the complainant. The complainant has sought the following reliefs vide instant complaint :-

i)       Compensate the complainant making payment of claim amount of Rs. 2,16,454/- with interest @ 18% p.a. ;

ii)      Pay Rs. 1,00,000/- for harassment as well as mental agony

iii)     Pay cost of complaint to the tune of Rs. 25000/-

Hence, this complaint.

2.       Upon notice, opposite party appeared through counsel and filed written statement contesting the claim of the complainant taking certain preliminary objections therein inter alia that  complainant has not come to this Forum with clean hands. Infact the complainant has suppressed the material facts from this Forum. As such the complainant is disentitled from seeking the relief ; that  the real state of affairs are that the complainant was hospitalized as per record of Fortis/Escort Hospital from 4.11.2014 to 6.11.2014  with the diagnosis CAD for which CAG and PTCA was done. The complainant was covered in BOI Med Policy since  17.1.2012 and was K/C/O CAD since  2003. BOI Policy covers expenses related to pre-existing disease CAD only after three years of continuation of the policy from the date of inception. Hence the claim was not payable. Even in respect thereof, PARK mediclaim TPA Private Limited also opined that the claim is not admissible vide letter dated 24.11.2014 . So much so, even cashless benefit was also denied by PARK Mediclaim TPA Pvt.Ltd on account of aforementioned facts  and as such the replying opposite party after considering the facts and circumstances  of the case, rightly arrived at the conclusion that the claim is not payable. Consequently  the impugned claim was rightly repudiated by the replying opposite party vide repudiation letter dated 12.12.2014. Office of the Insurance Ombudsman,Chandigarh vide order dated 15.5.2015 has also found the repudiation to be valid and legal. Even keeping in view the present treatment obtained by the complainant with date of admission as 4.11.2014 and date of discharge as 6.11.2016, it becomes quite evident that problem/disease suffered by the complainant was pre-existing. As such the impugned claim was not at all payable and was rightly repudiated. On merits facts narrated in the complaint have been specifically denied and a prayer for dismissal of the complaint with cost was made.

3.       In his bid to prove the case Sh.Updip Singh,Adv.counsel for the complainant tendered affidavit of the complainant Ex.C-1 alongwith documents Ex.C-2 to Ex.C-15 and closed the evidence on behalf of the complainant.

4.       To rebut the aforesaid evidence Sh.S.K.Davessar,Adv.counsel for the opposite party tendered affidavit of Sh. Vinod Kumar Mahajan Ex.OP1 alongwith documents Ex.OP2 to Ex.OP12 and closed the evidence on behalf of the opposite party.

5.       We have heard the ld.counsel for the parties and have carefully gone through the record on the file.

6.       On the basis of the evidence on record, ld.counsel for the opposite party has vehemently contended that the complainant is guilty of suppression of material facts . As a matter of fact the complainant suffered from heart problem in the year 2003 and got the treatment. But, however, the complainant did not bring the fact of the earlier heart ailment at the time of purchasing the new policy. As per new insurance policy, copy whereof is Ex.OP4, the complainant was entitled to medical reimburse regarding pre-existing disease i.e. heart ailment (CAD) after the expiry of three years from the inception of the Insurance policy. Since the policy in dispute was taken on 17.1.2012 and the requisite 3 years period did not expire on 6.11.2014, therefore, the claim of the complainant regarding pre-existing disease was validly repudiated vide repudiation letters dated 12.12.2014 Ex.C-9 and Ex,.C-10. The complainant filed appeal before Insurance Ombudsman, Chandigarh but his appeal was also rejected by that Forum vide  order dated 15.5.2015, copy whereof is Ex.C-12. It is further contended   that there is no deficiency in service on the part of the opposite party . The complainant has got no case absolutely and it is contended that the complaint may be dismissed accordingly.

7.       However, from the appreciation of the facts and circumstances of the case, it becomes evident that the complainant purchased mediclaim policy from Bank of India, Majith Mandi,Amritsar , who was the agent of National Insurance company , for himself , his wife and two children on payment of Rs.3616/- as premium which was inoperative w.e.f. 17.1.2012. During the operation of the Insurance policy in dispute, the complainant suffered heart problem and he was hospitalized at Fortis/Escorts Hospital, Amritsar  and he remained under treatment there w.e.f. 4.11.2014 to 6.11.2014. The complainant incurred an expenses of Rs. 2,16,454/- on his treatment. But, however , the mediclaim  filed on the basis of insurance cover, was rejected by the opposite party on the plea that three years have not since elapsed on 6.11.2014 for making a claim  on the basis of pre-existing disease. But, however, clause ‘e’ of document Ex.C-15 (Scope of cover) defines pre existing disease as under:-

“ Pre-existing disease shall mean any condition , ailment or injury or related condition(s) for which  you had signs or symptoms and/or were diagnosed and/or received medical  advice/treatment within 48 months prior to your first policy with us”.

8.       This document belongs to Bank of India, who has issued the policy. The opposite party has not challenged or denied the genuineness of the document. It is  the case of the complainant that although he got CAD treatment in the year 2003 & he got fully cured after getting the treatment. The second treatment i.e. the disputed treatment was obtained in the year 2014 only.

9.       As such there was a gap of 11 years in between the previous ailment and the second ailment in dispute. In view of clause ‘e’ of document Ex.C-15, the disease cannot be treated to be pre-existing & condition of 3 years applied by the opposite party to deny the claim was not applicable in the case of the complainant.  As such, the repudiation made by the opposite party was neither legal nor valid. There is deficiency in service on the part of the opposite party. The complainant has placed on record the bills of Fortis/Escorts Hospital Ex.C-2  to Ex.C-8 and perusal whereof shows that the complainant paid an amount of Rs. 2,16,454/-. Whereas the mediclaim cover available to the complainant as well as his wife and two children was to the tune of Rs. 2,50,000/-. The amount of Rs. 2,16,454/- claim made by the complainant was within prescribed limits of the Insurance policy. Consequently, instant complaint succeeds and the opposite party is directed to pay Rs.2,16,454/-  as reimbursement of the medical expenses incurred by the complainant. The complainant is also entitled to compensation of Rs. 10,000/- on account of harassment as well as  mental agony besides Rs. 2000/-  as cost of the complaint.   Opposite party is directed to comply with the order within 30 days from the receipt of copy of this order ; failing which, awarded amount shall carry interest @ 9% p.a from the date  of passing of the order until full and final recovery. .    Copies of the orders be furnished to the parties free of costs. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.

Announced in Open Forum

Dated : 17.05.2016

/R/                                                                         ( S.S.Panesar )

President

                              ( Kulwant Kaur Bajwa)           (Anoop Sharma)

                                                Member                         Member