DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, NORTH-WEST
GOVT. OF NCT OF DELHI
CSC-BLOCK-C, POCKET-C, SHALIMAR BAGH, DELHI-110088.
CC No: 1010/2016
D.No._______________________ Dated: _______________
IN THE MATTER OF:
SHANKER PANDIAN S/o SH. S. MANI,
R/o F-58, MANGOL PURI,
DELHI-110083. … COMPLAINANT
Versus
1. NATIONAL INSURANCE CO. LTD.,
DIVISIONAL OFFICE: 9, 302, N.N. MALL,
NEAR M2K CINEMA, SECTOR-3,
ROHINI, DELHI-110085.
2. PARK MEDICLAIM TPA PVT. LTD.,
702, VIKRANT TOWER,
RAJENDRA PLACE, NEW DELHI-110008. …OPPOSITE PARTY (ies)
CORAM:SH. M.K. GUPTA, PRESIDENT
SH. BARIQ AHMED, MEMBER
MS. USHA KHANNA, MEMBER
Date of Institution: 28.09.2016
Date of decision: 26.05.2020
SH. M.K. GUPTA, PRESIDENT
ORDER
1. The complainant has filed the present complaint against OPs under Section 12 of the Consumer Protection Act, 1986 therebyalleging that the complainant is the holder of a hospitalization benefit policy i.e. Pariwar Mediclaim vide policy no. 360400/48/16/8500000139
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and the complainant and his wife namely Smt. S. Renuka are covered under the said Mediclaim policy and the complainant has been Mediclaim policy holder of OP-1 for last 16 to 18 years and the complainant is continuing his policy and each year the policy gets renewed, but for last 8-10 years, the complainant is not having the policy documents containing terms & conditions and all the time it is represented that the policy gets renewed on the same terms & conditions. The complainant further alleged that the complainant was told by OP-1 through the agent namely Sh. Anil Kumar Sharma, agent code no.93 that they are covered for re-imbursement of the hospitalization charges for Rs.2,50,000/- and the complainant paid the premium amount of Rs.9,997/- vide receipt dated 07.04.2016 and the policy period from 11.04.2016 to 10.04.2017 (mid-night) and the complainant earlier was having a policy wherein the sum insured was Rs.2,00,000/- in the year-2013, the same was increased and the premium was also increased and from 2013 onwards the sum insured of Rs.2,50,000/-. The complainant further alleged that the complainant in the year-2009 was hospitalized for 3 days as he was seriously ill and at that time the sum insured was Rs.2,00,000/- and he was communicated that in case the final bill is raised for more than Rs.1,25,000/-, the company will pay more as per policy, however, at that time the final bill was less than the approved amount. As per the policy, the TPA i.e. OP-2 and the beneficiary no.2 namely Smt. S. Renuka wife of
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the complainant herein was admitted in the hospital for knee replacement bilateral and initially she was taken to Jaipur Golden Hospital but due to some family problem the treatment could not be done immediately and after a few days, she was again taken to Maharaja Agarsen Hospital and the hospital carried out communication with OP-2 and as per letter sent by Maharaja Agarsen Hospital, Punjabi Bagh, Delhi the estimated amount for the treatment indicated was Rs.1,62,000/- for hospitalization charges only and was sent directly to the Maharaja Agarsen Hospital, the approved amount of Rs.1,25,000/- as against the sum insured of Rs.2,50,000/- and on the other hand the condition of the patient was critical and the complainant was having no other option but to have the patient treated. Thereafter, the complainant managed the amount required in the treatment and the amount approved of Rs.1,25,000/- was also appropriated and after the knee transplant operation when the condition of the patient was stable the complainant again approached OP-2 and vide communication dated 24.05.2016, OP-2 made it clear that “hospital may please note that the amount exceeding total of Rs.1,25,000/- only will require further authorization” and no further grants since maximum available limit i.e. 50% of the sum insured for any one illness to the patient has been exhausted and the object of insurance is that it is a beneficial legislation and it must be construed in a way to give maximum benefit to the insured and the
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ultimate purpose of the insurance is that the insured must get the benefit and any technicality cannot be allowed to frustrate the basic purpose of insurance for which a person gets himself or his family insured and at no point of time the complainant was informed with regard to the said condition of maximum limit 50% of the sum insured for any one illness. The complainant further alleged that the complainant has been the policy holder for last 16-18 years and in the year-2009 he got the approval for more than 50% at first instance and since the final bill was less than the first approved amount otherwise the insurance company i.e. OP-1 has undertaken to pay any excess bill raised more than the approved amount. The complainant further alleged that the complainant approached OP vide communication dated 12.08.2016 duly received in the office of OP, however, no decision was taken by OP on the said representation and the action of OPs in refusing the legal claim amounts to deficiency in service on the part of OPs.
2. On these allegations the complainant has filed the complaintpraying for direction toOPs to jointly or severally pay a sum of Rs.2,25,000/- against the remaining insured amount of Rs.1,25,000/- as well as compensation of Rs.1,00,000/- for causing mental agony and harassment and also sought cost of proceeding.
3. Only OP-1 has been contesting the complaint and filed written statement. In the written statement, OP-1 submitted that the
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complaint is not maintainable and is liable to be dismissed. OP-1 further submitted that the present complaint has been filed on the ground of Pariwar Mediclaim policy bearing no. 360400/48/16/ 8500000139 valid from 11.04.2016 to 10.04.2017 (mid-night) covering the risk of the complainant and Smt. S. Renuka for a sum of Rs.2,50,000/- and the said policy was issued alongwith terms & conditions and the claim, if any, was always subject to terms & conditions of the policy under the clause 2 (c ) sub limit (a) the total expenses incurred for one illness is limited to 50% of sum insured and a request for cashless facility for the wife of the complainant was received from the hospital, accordingly as per the terms and conditions of the policy 50% of the sum insured i.e. Rs.1,25,000/- was approved by OP and was paid to the hospital directly and as the bill raised by the hospital was of Rs.3,08,957/- therefore, the balance payment was paid by the complainant and accordingly, on receiving the letter of the complainant for the balance payment he was informed by letter dated 04.10.2016 as the maximum limit available of 50% has already been exhausted and had paid and the claim for the balance amount is not payable. OP-1 further submitted that the complainant has cheated OP-1 while taking the insurance policy mentioning the age of the complainant and his wife as less than the actual age of the complainant and the complainant has taken the first family policy in the year-2009 from OP-1 valid from 11.04.2009 to 10.04.2010 and mentioned his date
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of birth as 04.07.1955 and the date of birth of his wife as 06.06.1961 whereas during the process of the claim it was revealed that the age of the complainant and his wife was 2 years more than the age mentioned in the proposal form filed by the complainant at the time of taking the first policy and he has paid less premium throughout all these years and the complainant is liable to pay a sum of Rs.12,644/- as balance premium against the Pariwar Mediclaim policies from 2008 to 2017 which amount he should refund to the insurance company.
4. The complainant filed rejoinder and denied the submissions of the OP-1 and furthersubmitted that OP-1 has taken a misleading plea.
5. In order to prove his case, the complainant filed his affidavit in evidence and also filed written arguments. The complainant also placed on record copy of insurance policy for the period from 11.04.2016 to 10.04.2017 (mid-night), copy of Prospectus of the insurance policy, copy of letter dated 24.05.2016 issued by OP-2, copy of request for cashless hospitalization for Medical Insurance policy, copy of final bill AAATM1408N002 dated 24.05.2016 of Rs.3,08,957/- issued by Maharaja Agrasen Hospital, Punjabi Bagh, Delhi, copy of final receipt no. 388967 dated 24.05.2016 of Rs.1,72,858/- issued by Maharaja Agrasen Hospital, Punjabi Bagh, Delhi, copy of Terms & Conditions for refund, copies of policies for the period from 11.04.2009 to 10.04.2010, 11.04.2011 to 10.04.2012, 11.04.2012 to 10.04.2013, 11.04.2013 to 10.04.2014,
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11.04.2015 to 10.04.2016 & 11.04.2015 to 10.04.2016and copy of letter dated 12.08.2016 sent by the complainant to OP-1 regarding claim of the Pariwar Mediclaim.
6. On the other hand, Ms. Artee, Administrative Officer of OP-1 filed her affidavit in evidence. OP-1 also placed on record copy of Certificate in respect of compliance of Section 64 VB of Insurance Act 1938, copy of insurance policy for the period from 11.04.2016 to 10.04.2017, copy of terms & conditions of the policy and copy of repudiation letter dated 04.10.2016. OP-1 also filed written arguments.
7. This forum has considered the case of the complainant as well asOP-1 in the light of evidence and documents placed on record by the parties. The case of the complainant has remained consistent and there is nothing on record to disbelieve the case of the complainant. The documents and evidence of the parties shows that the wife of the complainant was hospitalized in Maharaja Agrasen Hospital, Punjabi Bagh, Delhi for the treatment for knee replacement bilateral. This fact is not disputed by OP-1. The sole defence taken by OP-1 is that the complainant has concealed the material fact that the complainant’s disclosure aboutage of his wife is not correct and it was revealed that the age of the complainant and his wife was 2 years more than the age mentioned in the proposal form filled by the complainant at the time of taking 1st policy and the complainant has paid less premium throughout all
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theses years and thus the complainant has paid less amount of Rs.12,644/-which the complainant is liable to pay towards balance premium against the policies for the period from 2008 to 2017.
8. We have considered the point in issue. OP-1 has failed clarify as to on what basis the declaration about age given by the complainant at the time of taking the 1st policy is false. OP-1 has not placed on record any document to show that any notice was given to the complainant to place on record relevant certificates about their age. So, in the absence of any such evidence on behalf of OP-1 the defence raised by OP-1 cannot be considered and it appears that OP-1 has taken a false and bogus defence and in these circumstances, this Forum is of opinion that OP-1 was not justifiedin denying the claim of the complainant. Thus, OP-1 is held guilty of deficiency in service and unfair trade practice.
9. Thus, holding guilty for the same, we direct OP-1 to: -
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ii)To pay to the complainant an amount of Rs.30,000/- as compensation for causing harassment and mental agony.
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10. The above amount shall be paid by OP-1 to the complainantwithin 30 days from the date of receiving copy of this order failing which
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OP-1 shall be liable to pay interest on the entire awarded amount @ 10% perannum from the date of receiving copy of this order till the date of payment. If OP-1 fails to comply with the order within 30 days from the date of receiving copy of this order, the complainant may approach this Forum u/s 25/27 of the Consumer Protection Act, 1986.
11. Let a copy of this order be sent to each party free of cost as per regulation 21 of the Consumer Protection Regulations, 2005. Thereafter file be consigned to record room.
Announced on this 26th day of May, 2020.
BARIQ AHMED USHA KHANNA M.K. GUPTA
(MEMBER) (MEMBER) (PRESIDENT)
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UPLOADED BY : SATYENDRA JEET
