Delhi

North East

CC/210/2016

AJAY PAL SINGH VERMA - Complainant(s)

Versus

NATIONAL INSURANCE CO.LTD. - Opp.Party(s)

11 Dec 2017

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM: NORTH-EAST

GOVT. OF NCT OF DELHI

D.C. OFFICE COMPLEX, BUNKAR VIHAR, NAND NAGRI, DELHI-93

 

Complaint Case No. 210/16

In the matter of:

 

		Sh. Ajay Pal Singh Verma S/o Late Sh. Ram Singh R/o V-148, Arvind Nagar, Main Gamri Road, Near MCD Dispensary Ghonda, Delhi-110053.		Complainant
		Versus
		National Insurance Co. Ltd 1566/3, Church Road Kashmere Gate, Delhi-110006. (Through its Branch Manager/ Principal officer).		Opposite Party
			DATE OF INSTITUTION:		12.08.2016
			JUDGEMENT RESERVED ON :		01.12.2017
			DATE OF DECISION      :		11.12.2017

 

 

N.K.Sharma, President:-

Ms. Sonica Mehrotra, Member:-

 

Order by Ms. Sonica Mehrotra, Member:-

 

 

ORDER

1. Briefly stated, the case of the complainant is that he had purchased a ‘Hospitalization Benefit Policy’ by the name and style of Parivar Mediclaim for family bearing Policy No. 360501/48/11/8500000901 for cover of himself and his wife from the OP for the first time from 14.09.2011 to 13.09.2012 for a sum assured of Rs. 3,00,000/-.  The said policy was renewed from time to time and was lastly renewed on 14.06.2015 upto 13.09.2016 for sum assured of Rs. 4,00,000/- on payment of premium to the tune of Rs. 31,532/- . The complete schedule of policy is produced hereunder:

	Period of Insurance	Sum Assured	Amount of premium paid	Name of persons covered in the policy
	14/9/2011 to 13/9/2012			Sh. Ajay Pal Singh Verma (Self) & Smt. Shankari (wife)
	14/9/2012 to 13/9/2013
	14/9/2013 to 13/9/2014
	14/9/2014 to 13/9/2015
	14/9/2015 to 13/9/2016

 

Complainant further stated that in July 2015 he felt hoarseness of voice and difficulty in swallowing of food and notice and irregular growth in subgllotic area and on 31.07.2015. On consultation with B.L.K. Super Speciality Hospital, after some tests and observation, the complainant was diagnosed with Carcinoma Larynx and the complainant remained hospitalized and underwent treatment in the said hospital from 31.07.2015 to 24.10.2015 where the complainant underwent radio therapy and concurrent chemo therapy and received 66GY in 33 fractions radio therapy to head and neck region from 7.9.2015 to 24.10.2015 during the course of which treatment/ procedure an amount of Rs. 1,73,450/- was spent by the complainant. That thereafter the complainant had filed the claim with the OP for reimbursement of above mentioned medical expenses and the said claim was registered by OP as claim No. 360401/48/15/85/90000379. However, the OP instead of reimbursing of the claim, vide letter dated 19.02.2016, informed to the complainant that OP was closing his claim file on account of “PERIL/CAUSE OF LOSS NOT COVERED IN THE POLICY” The complainant contacted the agent of the OP on receipt of the said letter who had then collected the copy of the document again from the OP and assured the complainant of process of his claim. However, ultimately the complainant received a letter dated 4.3.2016 from the OP stating that the claim file has been closed due to “No response even after three reminders” whereas the complainant stated that on the contrary no such reminder or any other like letter was ever received by the complainant from the OP. The complainant lastly stated that such conduct on the part of OP is unfair trade practice and deficiency in service that has caused the complainant monetary loss as well as mental and physical harassment. The complainant has therefore vide the present complaint prayed to this Forum seeking relief by way of compensation from the OP as hereunder:-

1. Rs. 1,73,450/- towards cost of medical expenses incurred by the complainant in B.L.K super Speciality Hospital
2. Rs. 2,00,000/- towards mental and physical harassment
3. Rs. 33,000/- towards cost of litigation.

 

2. Notice was issued to the OP. Written statement was filed by the OP in which OP took the plea that the complainant had taken Parivar – Mediclaim policy and clause 1.2 thereof stipulated the coverage which are payable under the policy taken by the insured and has drawn our attention to clause 1.2 (E) thereof which stated that total expenses incurred for any one illness is limited to 50% of sum insured. It further argued that the complaint of the complainant is not maintainable as the complainant has taken Parivar-Mediclaim Policy and clause 1.2 (E) of the policy stipulates the COVERAGE which are payable under the policy taken by the insured.  Clause 1.2 (E) provides as under:-

1.2 (E) Total Expenses incurred for any one illness is limited to 50% of sum insured.

In furtherance to this arguments the OP submitted that policy taken by the complainant was Parivar Mediclaim policy and the claim is payable in terms of Parivar-Mediclaim policy.  In Parivar Mediclaim  policy there is cap on amount payable for a one illness i.e. 50% of the sum insured.  The sum insured under the policy taken by the complaint is Rs. 3,00,000/- The amount payable for one illness  in a policy year  can be only 50% of sum insured.  Thus in the present policy expenses for one illness is payable only up to Rs.1,50,000/- and not beyond that, which has already been exhausted by the complainant when he got admitted from 31/07/2015 to 18/08/2015 (for disease Malignant neoplasm of larynx (c-32)) with diagnosis of CARCINOMA LARYNX when the claim for Rs. 6,42,396/- was filed by complainant.  Complainant has filed present complaint for his admission for the period 07/09/2015 to 24/10/2015 for sum of Rs. 1,73,450/-.  It is again for diagnosis and treatment of CARCINOMA LARYNX (for disease Malignant neoplasm of larynx (C-32).  As the amount payable i.e. 50% of sum insured in policy period has already been exhausted (in previous admission) as such claim was not payable for admission from 07/09/2015 to 24/10/2015 (second time admission in same policy period). That the policy bearing no. 360401/48/8500001408 for the period 14/09/2014 to 13/09/2015 was issued to complainant subject to terms and conditions contained therein.  The sum insured under the policy was Rs. 3,00,000/- The complainant has already been paid 50% of sum insured as per the Clause no. 1,2 of the policy conditions.

The OP further argued that the present case is fit case for dismissal with cost as per section 26 of Consumer protection Act as the Complainant has filed false and frivolous complaint.  Complainant was well aware of the fact that he is entitled only for the amount of Rs. 1,50,000/- (50% of the sum insured for any one illness) which he has already received  despite knowing that he has exhausted the 50% of the amount of sum insured complainant still filed the present complaint.  It is submitted that earlier complainant filed the claim for Rs. 6,42,396/- and out of which Rs. 1,50,000/- has duly been passed and received by the complainant. The OP also argued that the present complaint of complainant is not maintainable and is liable to be dismissed as the complainant has not approached the Hon’ble Forum with clean hands. Complainant has concealed material from the Hon’ble Court so that he may get his claim passed by misusing the process of law.  Complainant in his entire complaint has not disclosed about his earlier admission in the hospital from 31/07/2015 to 18/08/2015 for which the filed the claim of Rs. 6,42,396/- and per policy conditions Rs. 1,50,000/-being 50% of sum assured was paid to the complainant. OP also contended that to mislead the Hon’ble Court complainant has presented his case as if he has been admitted in the hospital for the first time for period 07/09/2015 to 24/10/2015 which is complete false, wrong and devoid of merits. Lastly the OP contended that the claim of complainant is not maintainable as the benefit/sum payable under the policy during the policy period has already been availed by the complainant and that the complainant under the garb of complaint, is misusing the process of law is trying to fetch the amount more then to which he is entitled and already paid. 

 

3. Rejoinder and evidence by way of affidavit was filed by the complainant placing on record material documentary evidence on record in support of his claim viz insurance cover notes / policy schedule alongwith premium receipts, medical documents, prescriptions, case summary, cash payment receipts etc alongwith repudiation letters dated 19.02.2016 and 04.03.2016 issued by the OP . Evidence by way of affidavit was filed by the OP placing on record Parivar Mediclaim Prospectus, Letter dated 14.09.2015 written to by its TPA Park Mediclaim TPA Pvt. Ltd. apprising OP of payment made of              Rs. 1,50,000/- to the complainant for the treatment of Carcinoma Larynx Malignant Neoplasm of Larynx vide procedure of TOTAL LARYNGECTOMY WITH HEINTHYRO DECTOMY WITH RT MRND WITH LEFT EXTENDEDE SOMD undergone by the complainant at BLK Hospital for the period 31.07.2015 to 18.08.2015 in accordance with the available limit of 50% of sum insured for any one illness. The OP also placed on record letter dated 24.11.2015 and 26.11.2015 issued by the above mentioned TPA to the OP for rejection of claim of Rs. 1,73,450/- raised by the complainant for the treatment of Carcinoma  Larynx post of vide a procedure of external beam Radio therapy and cun-current-cemo therapy in BLK Hospital for the period 07.09.2015 to 24.10.2015 on grounds of exhaustion of maximum available  limit of 50%  to the claimant. The OP also placed on record repudiation letter dated 19.02.2016. 
4. Written arguments were filed by both the parties. The complainant argued that the details insurance policy containing the term and conditions were never either issued to the complainant by OP nor ever read out or made known to the complainant by the OP which had merely provided the complainant with cover note of policy alongwith policy schedule ‘ever since the purchase of policy on 14.09.2011 and subsequent renewal’. The complainant has relied upon the judgement of Hon’ble NCDRC in the case of New India Assurance Co. Ltd vs Jagtar Singh wherein referring the opinion of Hon’ble Supreme Court in the case of M/s Modern Insulators Ltd vs Oriental Insurance Co. Ltd AIR 2000 SC 1014, where it has been held that if copy of terms and conditions is not supplied to the insured at the time of issuing cover note and they are not explained then those terms and conditions are not binding upon that person and insurance company cannot repudiate any claim on the ground of exclusion clause. The complainant further argued that throughout the course of proceedings, the OP never filed copy of the policy but rather only a prospectus of the Parivar Mediclaim Policy which was unsigned and that too was never supplied to the complainant. Moreover the claim sheet of TPA for admission of the complainant for the period 31.07.2015 to 18.08.2015 and 07.09.2015 to 24.10.2015 were never provided to the complainant. Further the complainant argued that he was never in receipt of letter dated 26.11.2015  written by PARK MEDICLAIM PVT LTD, TPA of OP to OP wherein the said TPA had apprised OP that the complainant was hospitalized at BLK Super Speciality Hospital from 07.09.2015 to 24.10.2015 with diagnosis Carcinoma Larynx and for which he underwent Radiotherapy and Concurrent Chemotherapy and had written that “however, the maximum available limit to the claimant – 50% of S.I i.e. Rs. 1,50,000/- under Parivar Mediclaim Policy has already exhausted during settlement of previous claims. Hence, this claim is not admissible.” The complainant further argued that his claim in question is for the policy period 14.09.2015 to 13.09.2016 which was renewed for a sum insured Rs. 4,00,000/- and was valid and in force at the time of his hospitalization and he was never made aware or informed by the OP about the condition of entitlement to receive only 50% of the claim since no term and conditions of the policy were ever provided by the OP to him at any stage. The complainant further argued that he never received any amount against medical expenses incurred by him during the policy period 14.09.2015 to 13.09.2016 and the previous reimbursement of claim of Rs. 1,50,000/- made by OP to the complainant was pertaining to earlier policy and as such has no relevance to the present dispute and has therefore alleged unfair trade practice and deficiency in service on the part of OP.  The OP, in its written arguments contested the claim of the complainant and reiterated the stand taken by it in its written statement for justification of repudiation of claim and argued that there is a cap on amount payable for one illness which is 50% of the sum insured and therefore in the case of the complainant, 50% of the sum insured (Rs. 3,00,000/-) i.e. Rs. 1,50,000/- was already exhausted by / paid to the complainant as per clause no. 1.2 (E) of the policy conditions when he got admitted from 31^st July 2015 to 18^th August 2015 for treatment of carcinoma larynx and because the complainant, despite being fully aware of the provisions of the said policy, has filed the present complaint for his admission for the period 07.09.2015 to 24.10.2015 yet again for the diagnosis and treatment for same disease, the amount payable under the policy was already exhausted in the previous period and as such claim was not payable for the second period of admission. The OP further argued that the complainant had concealed from this Forum the fact of his earlier admission in the hospital for the period 31^st July 2015 to 18^th August 2015 for which he had filed the claim of Rs. 6,42,396/- and as per policy conditions Rs. 1,50,000/- was paid to the complainant by OP and was presenting his case as if he has been admitted in the hospital concerned for the first time for period 07.09.2015 to 24.10.2015 and therefore no unfair trade practice and deficiency in service could be attributed to the OP.
5. We have heard the rival contention of the parties and have thoroughly perused the case file alongwith documentary evidence placed on record by the parties herein in support / defence in the present case. The factum of Hospitalization Benefit / Parivar Mediclaim Policy having been taken by the complainant from the OP in w.e.f. 14.09.2011 and renewed from time to time till 13.09.2016 is not disputed. However it is noteworthy that the complainant was admitted prior to the period in question for which he is seeking claim which fact was revealed by the OP in its written statement in defence of their repudiation of the claim of the complainant as per                clause 1.2 (E) of the terms and conditions of the policy which stated that total expenses incurred for one illness is limited to 50% of the sum insured and therefore the complainant was not entitled to any claim with respect to the admission for same illness / Ailment / Disease in the same policy period. This defence was taken by the OP for repudiating the claim of the complainant vide its first repudiation letter dated 19.02.2016. However, a very valid objection was raised by the complainant that even in the written statement filed by the OP, a mere unsigned prospectus of Parivar Mediclaim was filed and nowhere and never were the policy and term and conditions attached therewith claimed to have been allegedly given to the complainant by the OP were placed on record by the OP throughout the proceedings.
6. Therefore, we find no merit in the defence taken by the OP that complainant was aware or had knowledge of the bar against claim operating against him as per clause 1.2 (E), lack of knowledge of which the OP cannot take refuge of or advantage of against the complainant. The second justification for repudiation of claim of complainant by the OP is a total departure from the previous stand of clause 1.2 (E). The OP vide second repudiation letter dated 04.03.2016, rejected the claim of the complainant on grounds “No Response Even After Three Reminders” but shockingly failed to place on record any or all of these so called reminders without any reference to the dates and contained thereof throughout the proceedings  and have maintained studied silence on this issue in their written statement as well as evidence and written arguments  which explains why the OP only filed the first repudiation letter dated 19.02.2016 alongwith their written statement. Therefore this bald defence of the OP vide second letter of repudiation is completely devoid of merit, unsupported by documentary evidence and cannot be entertained. The two repudiation letters are nothing but evasive tactics to repudiate the claim of the complainant on lame and untenable grounds and probably an afterthought not supported even with documentary evidence. Therefore the judgements relied upon by the complainant passed by Hon’ble NCDRC in the case of  New India Assurance Co. Ltd vs Jagtar Singh covers his stand that the insurance company is duty bound to disclose all material facts in their knowledge regarding term and conditions of the policy which in the present case the OP failed.
7. We therefore find OP guilty of unfair trade practice and deficiency in service. However, on equity, parity and natural justice, it would be unfair to grant compensation twice over for the same policy period even though the complainant was unaware of the terms and conditions which had kept the limit of reimbursement to 50% of sum assured for one illness in one policy period.  Therefore, it would be fair and justifiable for the interest and policy schedule of the OP that the complainant be awarded compensation for treatment falling strictly within the policy period 14.09.2015 to 13.09.2016 i.e. the bills from 14.09.2015 to 20.10.2015 be made reimbursable / payable by the OP to the complainant in order to avoid any overlap of expense incurred between policy period 14.09.2014 to 13.09.2015 (since complainant was discharged on 18.08.2015 as per first hospitalization and claim was already reimbursed by OP for the said period in accordance with the policy of 2014-15 in effect and validity).
8. We therefore award a sum of Rs. 1,61,000/- (Rupees One Lac Sixty One thousand only) for medical expenses incurred and covered in the relevant policy period of 14.09.2015 to 13.09.2016 to the complainant payable by the OP. We also award Rs. 20,000/- (Rupees Twenty Thousand Only) on account of mental pain and harassment and Rs. 15,000/- (Rupees Fifteen Thousand Only) as cost of litigation to the complainant payable by the OP. The OP is directed to comply with the order within 30 days of receipt of the same.
9.  Let a copy of this order be sent to each party free of cost as per regulation  21 of the Consumer Protection Regulations, 2005.
10.   File be consigned to record room.

 

(Announced on 11.12.2017)     

 

(N.K. Sharma) President

(Sonica Mehrotra)              Member