PER SHRI. S. G. CHABUKSWAR – HON’BLE  MEMBER

1)        This is a complaint for the reliefs of recovery of Rs.2,00,000/- amount of mediclaim policy from the Opposite Party Nos.1 & 2 jointly and severally @ 12% from the date of repudiation of the claim i.e. 10/12/2011 and Rs.50,000/- towards the compensation of mental & physical harassment and cost of complaint.

2)        The case of the Complainant is that Complainant No.1 is a consumer of the insurance services rendered by the Opposite Parties. Complainant No.2 is a voluntary consumer organization.  Opposite Party No.1 is a company rendering insurance services.  Opposite Party No.2 is the claim settlement agent of Opposite Party No.1.  The Complainant No.1 obtained mediclaim insurance coverage from Opposite Party No.1 effective from 27/02/2002 and said coverage has been renewed with continuity and without break as per the details given below –

 3)        On 15/05/2011 the Complainant No.1 for the first time developed certain symptoms, which were later diagnosed to be a Coronary Heart Disease.  Subsequently he was hospitalized in Hinduja Hospital from 15/08/2011 to 18/08/2011 where he underwent an Angioplasty termed PTCA (Percutaneous Transluminal Coronary Angioplasty).  The treatment and hospitalization expenses came to Rs.2,25,751/-.  As per the medical history recorded by the Hinduja Hospital the Complainant No.1 developed the symptoms of the heart problem two months prior to having undergone the PTCA procedure. The Angiography was done on 11/08/2011 and PTCA was performed in the mid August, 2011. It means the symptoms of heart problem manifested two months prior thereto i.e. sometime in mid – June, 2011.

4)        The Complainant No.1 had lodged a claim for the said amount of Rs.2,25,751/-. Opposite Party No.2 repudiated the claim on the grounds that there is medical history of hypertension and diabetes since past 10 years and the claim has arisen during the fourth year of the policy whereas the fifth year onwards i.e. after completion of four continuous years of insurance coverage.  The grounds of repudiation of the claim are malafide, incurred, unjustified and contrary to the terms of the policy. The heart problem was not pre-existing when the policy first incepted.  The heart problem arosed during the fifth year of the policy.  Hence claim is payable even if the ailment is considered pre-existing.  The Complainant No.1 received the repudiation letter on 10/12/2011. The Opposite Parties have adopted unfair trade practice and there is deficiency of service.  Hence, this complaint.

5)        Opposite Party No.1 submitted the written statement on 12/08/2013.  Opposite Party No.1 has contended that, after receipt of notice of this consumer complaint from the Consumer Disputes Redressal Forum, they (Opposite Party No.1) again scrutinized the claim and noticed that the insured is actually covered from 2006 therefore, arrived at the conclusion that the waiting period of 48 months under the policy for the coverage of pre-existing disease is completed on 27/02/2011.  The claim of the Complainant No.1 is admissible under the policy.  Opposite Party No.1 has informed to the Complainant No.1 by the letter dtd.28/02/2013 that Opposite Party No.1 verified the claim documents and found that due to oversight they had provided wrong information to Opposite Party No.2 about the date of coverage.

6)        Opposite Party No.1 has also informed to Opposite Party No.2 to re-open the claim by the letter dtd.18/02/2013.  Opposite Party No.2 requested o Opposite Party No.1 for obtaining original claim file for processing as it is mandatory as per the terms of mediclaim policy. The original claim file has been already returned to the Complainant No.1. The Complainant No.1 also resubmitted the original claim file with Opposite Party No.1 and it is submitted by them (Opposite Party No.1) to Opposite Party No.2 and requested for reprocess the claim.  Accordingly Opposite Party No.2 reprocessed the claim and informed to Complainant No.1 to send the Bank details to enable them to make payment of claim.  Opposite Party No.1 has followed up the matter with the Complainant through telephone various times, however, the Complainant neither given his bank details nor replied to the same.  Lastly Opposite Party No.1 has shown readiness and willingness to pay the claim amount as per the terms and conditions of the insurance policy. 

7)        Opposite Party No.2 served with the notice but remained absent, hence, complaint proceeded ex-party against Opposite Party No.2. Opposite Party No.1 has submitted affidavit of evidence of Dilip B. Kadam, Divisional Manager of New India Insurance Company and documents annexure A to D.  Opposite Party No.1 has also submitted the same documents alongwith it’s written statement.  Opposite Party NO.1 has filed written notes of arguments on 11/04/2014.  The Complainants have filed their written notes of arguments on 24/06/2014.

8)        We have considered the above evidence, pleadings and documents submitted by both the parties. We heard Shri. Jehangir B. Gai, Ld. Representative of the Complainants and Shri. S.S. Singh, Ld.Advocate for Opposite Party No.1. 

9)        Admittedly Complainant No.1 has first obtained Parivar Mediclaim Insurance Policy from Opposite Party No.1 as mentioned in above para no.2.  The Complainant No.1 for the first time developed certain symptoms of Coronary Heart Disease on 15/05/2011.  He was admitted in the Hinduja Hospital from 15/08/2011 to 18/08/2011, where he underwent an angioplasty (medically termed PTCA or Percutaneous Transluminal Coronary Angioplasty). He incurred the expenses Rs.2,25,751/- for the treatment and hospitalization. The Complainant No.1 had submitted the claim with the Opposite Party No.2 on 10/12/2011 Opposite Party No.2 repudiated the claim of Complainant No.1. However, Opposite Party No.1 has admitted by the written statement that, after receipt of notice of this complaint, they scrutinized the claim file again and noticed that the claim of Complainant No.1 has been wrongly repudiated due to their oversight & mistake. Mr. Dilip B. Kadam, Divisional Manager of Opposite Party No.1 has stated on oath in his affidavit of evidence all the facts narrated in the written statement dtd.13/08/2013. Mr. Dilip Kadam has stated in his affidavit of evidence the Opposite Party is ready and willing to pay the claim amount as per the terms and condition of insurance policy. Admittedly sum insured under the policy is Rs.2,00,000/-. The Complainants have also restricted their claim of insurance upto Rs.2,00,000/-.

10)      We have gone through the written argument of Opposite Party No.1 submitted on 11/04/2014. Opposite Party has mentioned in the written argument that Complainant is entitled to 50% of the sum assured as per the clause 1.0 of the policy.  Opposite Party has quoted above clause in para 1 of the written argument as under –

“Clause 1.0 by way of providing a specific note inter-alia it is stated that Company liability would arise if the treatment of the deceased or injury contracted/suffered is incepted during the policy period.  Total expenses incurred for any one illness is limited to 50% of sum assured per family.” 

We have gone through the entire clause 1.0(a) of the policy.  It clearly goes to show that Opposite Party has not mentioned the second party of the said clause.  The clause 1.0 (a) runs as under –

Note: (a) Company’s liability would arise if the treatment of disease or injury contracted/ suffered is incepted during the policy period.  Total expenses incurred for any one illness is limited to 50% of Sum Insured per family.  Company’s liability in respect of all claims admitted during the period of insurance shall not exceed the Sum Insured mentioned in the Schedule.”

As per the above clause Company is liable in respect of all claims admitted during the period of insurance shall not exceed the sum insurance mentioned in the schedule.  It is not the case of the Opposite Party No.1 that Complainant No.1 or his wife has submitted mediclaim during the period of insurance for which Complainant has submitted present claim.

11)      Opposite Party No.1 neither pleaded in the written statement nor Mr. Dilip Kadam stated on oath in the affidavit that Complainant No.1 is entitled only 50% of the insurance amount.  Opposite Party No.1 remained silence about second part of clause 1.0 (a) of the policy.  In view of this we are of the opinion that there is no substance in above new point raised by the Opposite Party No.1 in the written argument.

12)      In view of the admission given by the Opposite Party No.1 in the written statement, affidavit of evidence, we hold that Complainant No.1 is entitled to the insurance amount Rs.2,00,000/-.  In view of the facts of the case it is just to award interest on above amount @ 9% p.a. from the date of repudiation letter dtd.10/12/2011. Opposite Party No.1 wrongly repudiate claim of the Complainant No.1 on 10/12/2011.  Opposite Party No.1 has admitted the said fact in the written statement and affidavit of evidence.  Opposite Party No.1 has also expressed it’s regrets for the inconvenience caused to the Complainant No.1 due to repudiation of claim.  The Complainant No.1 has suffered physical and mental harassment therefore, he should be compensated by way of payment of amount.  The Complainant No.1 has to approach this Forum due to repudiation of his claim by Opposite Party No.2. Considering the facts, circumstances of the case we are of the view that it is just to grant Rs.10,000/- to the Complainant No.1 towards compensation for mental & physical harassment and Rs.3,000/- towards the cost of this litigation.  In the result complaint deserves to be allowed against the Opposite Party Nos.1 & 2.  Hence, we proceeds to pass following order –

O R D E R

i.     Complaint No.183/2012 is partly allowed with cost against Opposite Party Nos.1 & 2.

ii.    Opposite Party Nos.1 & 2 are directed to pay to the Complainant No.1 Rs.2,00,000/- (Rs.Two Lakhs Only) insurance amount

       with interest @ 9% p.a. from 10/12/2011 till the realization of amount.

iii.   Opposite Party Nos.1 & 2 are directed to pay to the Complainant No.1 Rs.10,000/-(Rs.Ten Thousand Only) towards physical &

      mental harassment.

           iv.   Opposite Party Nos.1 & 2 are directed to pay to the Complainant No.1 Rs.3,000/- (Rs.Three Thousand Only) towards the cost of

                 complaint.

                  v.   Opposite Party Nos.1 & 2 are directed to pay amount mentioned in above para Nos. ii to iv to the Complainant No.1 within 45

                       days from the date of service of this order.

                vi.    Certified copies of this order be furnished to the parties.