Punjab

Fatehgarh Sahib

CC/87/2015

Shiv Kumar - Complainant(s)

Versus

National Insurance Co. - Opp.Party(s)

Sh NS Toor

28 Feb 2017

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FATEHGARH SAHIB.

                         Consumer Complaint No.87 of 2015

                                                                Date of institution:  01.10.2015                        

                                                             Date of decision   :  28.02.2017

Shiv Kumar aged about 58 years son of Dharam Pal R/o Press Well Industries, Near Shiv Mandir, Behind Police Station, Sirhind, Tehsil and District Fatehgarh Sahib.

……..Complainant

Versus

1. National Insurance Company, having its head office at Midleton Street, P.O. Pox No.9229, Kolkata-700071 through its Authorized Signatory.
2. National Insurance Company Ltd., having its Branch office Sirhind, G.T.Road, Sirhind, Tehsil and District Fatehgarh Sahib through its Branch Manager.

 

 …..Opposite parties 

Complaint under Sections 12 & 13 of the Consumer Protection Act

Quorum

Smt. Veena Chahal, Member           

Sh. Amar Bhushan Aggarwal, Member

         

Present :      Sh. N.S.Toor, Adv. Cl. for the complainant.

                Sh. Amit Gupta, Adv.Cl. for opposite parties.

 

ORDER

By Amar Bhushan Aggarwal, Member

                Complainant, Shiv Kumar aged about 58 years son of Dharam Pal R/o Press Well Industries, Near Shiv Mandir, Behind Police Station, Sirhind, Tehsil and District Fatehgarh Sahib, has filed this complaint against the Opposite parties (hereinafter referred to as “the OPs”) under Sections 12 & 13 of the Consumer Protection Act. The brief facts of the complaint are as under:

2.              The complainant availed Parivar Mediclaim Family Policy in the year 2011 from the OPs and the same was renewed again for the period of 11.11.2012 to 10.11.2013.  The complainant again availed/got issued Parivar Mediclaim Policy bearing No.404702/48/12/85000000091 for the period of 11.11.2013 to 10.11.2014 from OPs by paying an amount of Rs.15,550/-through their official agent and at the time of issuing the said policy by the OPs, there was no pre-existing disease to the complainant and the complainant was medically and physically fit.  Thereafter due to pain in the left side of his back the complainant had to remain admitted from 01.05.2014 to 03.05.2014 in Fortis Hospital, Mohali as the said Hospital was on the Panel for the said policy. After admission in the said hospital, it was found that the complainant was suffering from the diseases of hypertension and diabetes and the said diseases are recent onset and for the treatment of the said diseases, an operation was conducted by the concerned doctor of said hospital.  Due to clerical error, the doctor of the Fortis Hospital has mentioned in the OPD record that the  complainant is suffering from Hypertension and Diabetes since 15 years and 12 years respectively. The doctor of the hospital has also issued clarification certificate regarding the said fact.  It is further stated that at the time of admission the OPs, on the request of the said hospital, approved the cashless facility to the complainant for his treatment but at the time of discharge, they declined the cashless service as Hypertension and Diabetes record did not match with the record of Fortis Hospital due to said clerical mistake. The complainant consulted the concerned doctor, namely; Sh. R.K. Jaswal, about the said fact as he was suffering from the said disease recently. Then clarification letter regarding the said clerical mistake was issued by the said doctor.  The complainant had to spend an amount of Rs.2,87,151/- for his treatment.  Thereafter, the complainant supplied all the necessary documents alongwith clarification certificate to the OPs for releasing the claim amount but the OPs did not disburse claim amount of the said policy to the complainant. The complainant approached the OPs many times regarding the payment of the claim but all in vain. The act and conduct of the OPs amount to deficiency in service on their part. Hence, this complaint for giving directions to the OPs to pay Rs.1,00,000/- as compensation for un-necessary harassment and mental pain, Rs. 10,000/- as cost of litigation and Rs.2,87,151/-  along with interest as expenses incurred by the complainant on his treatment.  

3.             The complaint is contested by the OPs, who filed joint written reply. In reply to the complaint they raised certain preliminary objections, inter alia, that the complainant has not come to the court with clean hands. As regards to the fact of the complaint, OPs stated that the complainant requested for cashless hospitalization for his treatment and admitted in Fortis Hospital, Mohali on 01.05.2014 but the said request was declined by Vipul MedCorp TPA Private Limited, Gurgaon vide letter dated 03.05.2014 stating that " As per preauth history of HTN is 1 year and DM last 2 year but as per document of Fortis Hospital history of HTN is 15 years and DM 12 years. There is a discrepancy found in provided document. Hence, cashless may not be granted at this stage. Kindly submit your all original document for possible reimbursement. Previously approved amount stand cancelled". Thereafter, the complainant lodged the medical reimbursement claim with TPA through letter received on 09.05.2014. The said claim was duly processed as per the terms and conditions of the policy and the claim was not found tenable by the TPA and the company was informed in this regard through letter dated 14.08.2014. Accordingly, the OPs issued repudiation letter dated 22.08.2014 in accordance with Exclusion Clause 4.1 of the policy. As per clause 4.1 of the policy, "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".  It is further stated that the claim of the complainant was not found tenable as the disease(K/C/O- Hypertension) as per prescription dated 23.04.2014 is pre- existing as the patient is suffering from same since 15 years and suffering from disease(D.M) since 12 years.  The complainant further tried to manipulate the fact by producing clarification dated 03.05.2014.  The said clarification was duly considered and investigated and it was found that the complainant was again manipulated the said fact and accordingly the claim of the complainant stands repudiated vide letter dated 07.07.2015. The claim of the complainant was duly processed as per the terms and conditions of the policy and as such there is no deficiency in service on the part of the OPs.  After denying the other averments made in the complaint, OPs prayed for dismissal of the complaint.

4.             In order to prove his case the complainant tendered his affidavit Ex. C-1 along with attested copies of documents Ex. C-2 to Ex. C-17, certified copy of order of this Forum annexure A and closed the evidence. In rebuttal the OPs tendered in evidence affidavit of Sh. Lalit Mohan Bansal Ex. OP-1, affidavit of Arvind Bakshi as Ex. OP-2, copy of insurance policy with terms and conditions Ex. OP-3(13 pages), request for cashless Ex. OP-4,  copy of authorization letter Ex. OP-5, copy of letter dated 03.05.2014 Ex. OP-6, copy of rejection sheet Ex. OP-7, copy of investigation Ex. OP-8(7 pages),  copy of letter dated 14.08.2014 Ex. OP-9, copy of letter dated 22.08.2014 Ex. OP-10, copy of claim form Ex. OP-11 and closed the evidence.

5.             The Ld. counsel for the complainant argued that the complainant was insured under Parivar Mediclaim cashless policy. The complainant got treatment from the empanelled hospital of the OPs.  Firstly the cashless treatment was denied and afterwards the claim was repudiated on the basis of alleged pre-existing disease. But there was no pre-existing disease at the time of taking the mediclaim policy. Diseases of Hypertension and diabetes were of recent onset but due to clerical mistake, in the OPD record it was wrongly mentioned that complainant was suffering from Hypertension since 15 years and Diabetes since 12 years. The claim of Rs.2,87,151/- has illegally been rejected by the OPs without any reason. Thus the OPs have committed deficiency in service and indulged in unfair trade practice. The Ld. counsel submitted various judgments in support of his contention titled as National Insurance Company Ltd. Vs. Suraj Parkash in II(2005) CPJ 3, ICICI Prudential Life Insurance Company Ltd. Vs. Veena Sharma & Anr. in IV(2014) CPJ 580(NC) and thus pleaded for the acceptance of his complaint and penalizing the OPs for deficiency in service and unfair trade practice.

6.             The Ld. counsel for the OPs argued that the claim of the complainant was not tenable since the diseases of Hypertension and Diabetes as mentioned in the OPD prescription dated 23.04.2014 were pre-existing. The insured was suffering from Hypertension since 15 years and that from Diabetes since 12 years. It has also been observed by the panel doctors that the insured had been manipulating the facts whereas the diseases were pre-existing. The insured has also suppressed the material fact of pre-existing diseases at the inception of the policy and has left the columns as blank in the proposal forms thereby avoiding the extra premium on the pre-existing diseases. There is provision of cover for the pre-existing diseases like diabetes and hypertension by paying the additional premium by the insured which had evaded. In view of the material facts being concealed and as per policy terms and conditions, the claim of the complainant was repudiated. There is no deficiency in service or unfair trade practice on the part of the OPs. After denying the other averments made in the complaint, Ld. counsel pleaded for the dismissal of the complaint. The Ld. counsel submitted various judgments in support of his contention titled as Satwant Kaur Sandhu Vs. New India Assurance Company Limited in(2009) 8 Supreme Court Cases 316, Chandubhai C Shah Kike Electronics Vs. United India Insurance Co. & Anr in 2011 SCC Online NCDRC 60 and United India Insurance Company Ltd. Vs. Dharam Dev Verma in 2013 SCC online NCDRC 318.

7.             After hearing the Ld. counsel for the parties and going through the pleadings, written versions, evidence produced and oral arguments, we find force in the submissions of the Ld. counsel for the OPs. That the complainant was suffering from the pre-existing diseases of Hypertension and Diabetes since 15 years and 12 years respectively at the time of taking the mediclaim policy as was evident from the OPD card dated 23.04.2014(Ex. OP-8 page 5). It is the first contact of the complainant/insured with the doctor when the doctor records the history of disease of the patient.  It cannot be a clerical mistake, since it is not recorded by any official/clerical staff of the hospital. It is recorded in the hands of a doctor, which cannot be denied.

                Various judgments submitted by the Ld. counsel for the complainant are not relevant to the present case. The judgment of Apex Court titled as Satwant Kaur Sandhu Vs New India Assurance Company Limited in (2009)8 SCC 316 and other judgments submitted by Ld. counsel for the OPs fully support their contention and the claim has been rightly repudiated by the OPs.

8.             In view of the above discussion, we find no merit in the contention of the complainant and dismiss the complaint. No order as to costs. Parties to bear their own costs.

9.             Copy of the order be sent to the parties free of cost and thereafter the file be consigned to the record room.

Pronounced

Dated:28.02.2017

 

(Veena Chahal)

Member

                                                                                                                                                                                                                                                                                                          (A.B.Aggarwal)

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