Punjab

Ludhiana

CC/19/214

Mohinder Pal Singh - Complainant(s)

Versus

National Insurance Company Limited - Opp.Party(s)

Anand Sabharwal ADv.

01 Sep 2022

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No: 214 dated 09.05.2019.                                                       Date of decision: 01.09.2022.

 

Mohinder Pal Singh S/o. S. Karnail Singh, aged 72 years R/o.D-12, Flower Enclave, Near Dugri Urban Estate, Phase-3, Ludhiana-141013.                                                                                                           ..…Complainant 

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1. National Insurance Company Limited, B-30/154, 2^nd Floor, Kailash Nagar, Sherpur, Ludhiana through its Branch Manager.                        
2. M/s. Vipul Medcorp TPA (P) Ltd., Ferozegandhi Market, Ludhiana through its Manager/MD.                                                                                                                                                     …..Opposite parties 

Complaint under Section 12 of the Consumer Protection Act.

QUORUM:

SH. K.K. KAREER, PRESIDENT

SH. JASWINDER SINGH, MEMBER

COUNSEL FOR THE PARTIES:

For complainant            :         Sh. Anand Sabherwal, Advocate.

For OP1                         :         Sh. D.R. Rampal, Advocate.

For OP2                                  Complaint against OP2 not admitted vide order                                        dated 23.05.2019.

ORDER

PER K.K. KAREER, PRESIDENT

1.                In brief, the case of the complainant is that in the year 2010, he purchased a medi-claim insurance policy from OP1 for a period of one year with assured sum of Rs.1,00,000/-. The complainant along with his wife Manjit Kaur, daughter Loveleen Walia and son Jatin Walia were covered under the policy. The policy was renewed from time to time.

2.                It has been further alleged that in the year 2015, wife of the complainant was hospitalized in Dayanand Medical College and Hospital, Unit Hero DMC Heart Institute and Hospital, Ludhiana from 28.05.2015 to 03.06.2015. At that time, the complainant was having policy No.401314/48/14/8500000263 with sum assured of Rs.2,00,000/- and the policy was valid from 17.07.2014 to 16.07.2015. The complainant incurred expenditure of Rs.54837/- on her treatment but the claim was closed as no claim by the OPs and in this regard, the complainant has filed complaint under Consumer Protection Act. The wife of the complainant again fell ill and was hospital with DMC and Hospital from 15.10.2016 to 24.10.2016 and again from 30.11.2016 to 13.12.2016. She was treated for Coronary Angiography: Double Vessel Disease with stent in LAD PTCA with stenting to RCA. The complainant lodged a claim of an amount of Rs.2,15,275/- and, thereafter, an amount of Rs.1,67,043/- plus medical expenses of Rs.15,396/- was lodged but the OPs made a payment of Rs.1,50,000/- only and repudiated the claim vide letter dated 16.03.2017. The OPs further issued letter dated 11.05.2017 stating that as per clause 4.1 benefits for pre-existing disease are not available until 36 months of continuous coverage. Non-payment of the claim on the part of the OPs to the extent of Rs.1,50,000/- amounts to deficiency of service on the part of the OPs.  Hence the complaint whereby it has been requested that the OPs be directed to pay the remaining amount of Rs.1,50,000/- with interest @18% per annum from 11.05.2017 onwards and the OPs be further made to pay a compensation of Rs.1,00,000/- and litigation expenses of Rs.10,000/-.

3.                The complaint as against OP2 was not admitted vide order dated 23.05.2019.

4.                The complaint has been resisted by the OP1. In the written statement filed on behalf of the OP1, it has been, inter alia, pleaded that the complaint is not maintainable and is liable to be dismissed. According to OP1, on receipt of the claim in respect of the treatment of Manjit Kaur, the same was scrutinized and it was found that the applied liability was Rs.1,50,000/- which had already been exhausted. According to OP1, the patient Manjit Kaur was diagnosed to be a case of Type II diabetes mellitus, hypertension, hypothyroidism, CAD Post PTCA to LAD, Acute Coronary Syndrome. She underwent CAG and PTCA with stenting to RCA. As the patient was a known case of hypertension and diabetes mellitus for the last 20 years, the applied liability of OP1 was Rs.1,50,000/- which had already been exhausted and, therefore, the claim was repudiated vide letter dated 16.03.2017. The complainant sent one letter dated 08.05.2017  after receipt of the repudiation letter dated 16.03.2017 and in response to the said letter, OP1 again gave detailed facts and reasons in its letter dated 11.05.2017. It was specifically mentioned in the said letter that as per the exclusion clause 4.1 of the policy, the claim of Rs.3,00,000/- was not admissible and the sum assured as per the policy for the year 2013-2014 was Rs.1,50,000/- and the amount of Rs.3,00,000/- was not payable. According to OP1, benefits of pre-existing disease were not available until 36 months of continuous coverage from the inception of the policy. As the policy was under the continuity w.e.f. 17.07.2013 only and not from the year 2010 as alleged by the complainant, the claim has been rightly considered to the extent of Rs.1,50,000/- only. Therefore, the complainant is nto entitled to the alleged amount. The other allegations made in the complaint have been denied as wrong and a prayer for dismissal of the complaint has also been made.

5.                In evidence, the complainant submitted his affidavit Ex. CA along with documents Ex. C1 to Ex. C18 and closed the evidence.

6.                On the other hand, the counsel for OP1 tendered affidavit Ex. RA of Sh. Ravinder Kumar Sidana, Divisional Manager of OP1 along with affidavit Ex. RB of Sh. Ashwani Kumar of Vipul Medcorp Insurance TPA Pvt. Ltd. along with documents Ex. R1 and Ex. R2 and closed the evidence.

7.                We have heard the arguments advanced by the counsel for the parties and have also gone through records.

8.                In this case, the dispute is with regard to the reimbursement of the hospitalization charges of Manjit Kaur, wife of the complainant from 15.10.2016 to 24.10.2016 and then again from 30.11.2016 to 13.12.2016 with DMC Hero Heart Hospital, Ludhiana. After aforesaid hospitalizations, the complainant lodged a claim of Rs.2,15,275/- and another claim of Rs.1,67,043/- plus Rs.15,396/- as stated in para No.6 of the complaint. As against the said claims, the OPs have paid only a sum of Rs.1,50,000/- and the remaining part of the claim has been repudiated vide letter Ex. C12 dated 16.03.2017as well as letter Ex. 10 dated 11.05.2017. In the letter Ex. C12, the claim is said to have been repudiated on the ground that Manjit Kaur has been a known case of diabetes mellitus and hypertension so the applied liability has been exhausted. In the letter Ex. C10 dated 11.05.2017 also, it has been stated that the patient has been a known case of hypertension and diabetes mellitus for the last 20 years and as per the policy terms and conditions more particularly exclusion clause 4.1 the benefits for pre-existing disease will not be payable in any condition as defined in the policy until 36 months of continuous coverage has exhausted since the inception of the first policy and, therefore, the claim for Rs.3,00,000/- was not admissible. It is the admitted case of OP1 in the written statement that the policy of the complainant was in continuity since 17.03.2013 as stated in para No.4 of the preliminary objections of written statement filed by OP1. If the policy was in continuity from 17.07.2013, three years expired on 17.07.2016 in the policy Ex. C2 which is valid from 17.07.2017 to 16.07.2018, the sum assured mentioned is Rs.3,00,000/-. Similarly, in the policy Ex. C3 valid from 17.07.2016 to 16.07.2017, the sum assured is Rs.3,00,000/-. The claims in respect of the hospitalization from 15.10.2016 to 24.10.2016 and then again from 30.11.2016 to 13.12.2016 falls in the policy Ex. C3 and waiting period of 3 years, if any, under clause 4.1 of the policy expired on 17.07.2016. Therefore, the said clause could not have been invoked to confine the reimbursement of the claim to the extent of Rs.1,50,000/-. Therefore, the partial repudiation of the claim cannot be said to be justified and in our considered view, it would be just and proper if OP1 is  directed to reimburse the remaining part of the claim strictly in accordance with terms and conditions of the policy by considering the sum assured under the policy as Rs.3,00,000/-.

9.                As a result of above discussion, the complaint is allowed with direction to OP1 to reimburse the remaining part of the claim strictly in accordance with terms and conditions of the insurance policy by considering the sum assured under the policy as Rs.3,00,000/- within 30 days from the receipt of copy of order. OP1 is further made to pay composite costs and compensation of Rs.7,000/- (Rupees Seven Thousand only) to the complainant within 30 days from the date of receipt of copy of order. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.

10.              Due to rush of work and spread of COVID-19, the case could not be decided within statutory period.

 

                             (Jaswinder Singh)                            (K.K. Kareer)

                    Member                                           President

Announced in Open Commission.

Dated:01.09.2022.

Gobind Ram.

Mohinder Pal Singh Vs National Insurance Co. Ltd.               CC/19/214

Present:       Sh. Anand Sabherwal, Advocate for the complainant.

                   Sh. D.R. Rampal, Advocate for the OP1.

                   Complaint against OP2 not admitted vide order dated 23.05.2019.

 

                   Arguments heard. Vide separate detailed order of today, the complaint is allowed with direction to OP1 to reimburse the remaining part of the claim strictly in accordance with terms and conditions of the insurance policy by considering the sum assured under the policy as Rs.3,00,000/- within 30 days from the receipt of copy of order. OP1 is further made to pay composite costs and compensation of Rs.7,000/- (Rupees Seven Thousand only) to the complainant within 30 days from the date of receipt of copy of order. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.

 

                             (Jaswinder Singh)                            (K.K. Kareer)

                    Member                                           President

 

Announced in Open Commission.

Dated:01.09.2022.

Gobind Ram.