Haryana

Charkhi Dadri

cc/236/2019

Ashutosh Goel - Complainant(s)

Versus

National Insurance Company Ltd, - Opp.Party(s)

Sh. J. B. Yadav

30 May 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL

COMMISSION, CHARKHI DADRI. 

 

        Complaint No.         236 of 2019                   Date of Institution:  26.12.2019

        Date of order:        30.05.2024   

 

Ashutosh Goel aged about 35 years, C/o Ram Kishor & Co. ,Anaj Mandi, Charkhi Dadri, Tehsil & District Charkhi Dadri, Haryana.

                            ..Complainant.

                    VERSUS

1. National Insurance Company Limited, Division VIII, Second Floor, C 3, Puja House, Milan Cinema Complex, Karampura New Delhi-1100105, through its Manage/Authorized signatory.
2. Branch Manager, National Insurance Company Limited, Branch Office Near Geeta Nikean, Loharu Road, Charkhi Dadri, Tehsil and District Charkhi Dadri.
3. Safeway TPA Services Pvt. Ltd., HO,815, Vishwas Sadan, District Center, Janak Puri, New Delhi-110058, through its Manager/authorized signatory.

                           ..Opposite parties.

COMPLAINT UNDER SECTION 35 OF THE CONSUMER PROTECTION ACT, 2019

Before- Hon’ble Sh. Manjit Singh Naryal……PRESIDENT.

        Hon’ble Sh. Dharam Pal Rauhilla……………MEMBER.

 

Argued by:   Sh. Amit Kumar Dagar, Adv. for complainant.

             Sh. Vinod Kumar Chahar, Adv. for OP No.1.

             OP no.2&3 exparte.

 

 

O R D E R

 

1.       Shri Ashutosh Goel (hereinafter referred to as “the complainant”) has filed the present complaint against the opposite parties (hereinafter referred to as “the OPs”) alleging that the complainant had purchased a health care policy no.36030050170006467 for the period w.e.f. 22.01.2018 to 21.01.2019 for himself, his wife and daughter Sakshi title as “Parivar Mediclaim for Family”.  It was alleged that during the validity of insurance policy, the complainant’s daughter suffered from disease severe Anaemia and remained hospitalized from 06.12.2018 to 09.12.2018 at Sri Balaji Action Medical Institute (hereinafter referred as “Hospital”), A-4, Pashim Vihar, New Delhi. Complainant disclosed the mediclaim insurance policy to the treating doctor and handed over the relevant papers to the concerned hospital authorities.  The complainant had intimated the OPs and also supplied all the relevant papers to the OPs and submitted claim vide claim no. NI-3-43303 dt.03.01.2019 for reimbursement of expenses for Rs.51,242/- incurred on treatmenet by making payment to hospital. But in response thereto the National Insurance Co. Ltd. had issued the letter dated 12.02.2019 to the complainant whereby the claim was repudiated on the ground of non-disclosure of material fact i.e. pre-existing disease (Thalassemia is a genetic blood disorder).  The complainant further alleged that the repudiation of his lawful claim was wrong and illegal.  So, the complainant has come to this Commission and filed the present complaint with the prayer to direct the OPs to make the payment of Rs.51,242/- alongwith interest, compensation and litigation expenses.

2.       Upon notice, OP no.1 appeared and filed his written statement.  The OPs in written statement have taken preliminary objections like maintainability, locus-standi and suppression of material facts.  It was submitted that the on scrutiny of the claim documents it was found that Baby Sakshi aged 01 year had availed treatment in Sri Bala Ji Action Medical Institute from 06/12/2018 to 09/12/2018 with the diagnosis of severe Anemia. The cashless for this claim was denied as etiology of Anemia was not confirmed, the insured put the claim for reimbursement with the HPLC report, the report is suggestive of Beta-thalassemia homozytgous (thalassemia is a genetic blood disorder,alpha thalassemia disease and beta thalassemia disease, Beta thalassemia major is a serious illness. Symptoms appear in the first two year of life and include paleness of the skin, poor appetite, irritability and failure to grow. Proper treatment includes routine blood transfer fusion and other therapies). It is further alleged that it is an anomaly since birth which is not payable. Hence, the claim was repudiated on genuine grounds and complainant was intimated vide letter dated 12.02.2019 (Annexure.C4).  There is no deficiency in service on the part of the OP no.1. The complainant is not entitled to get any claim amount from the OP no.1 and thus, prayed for the dismissal of the present complaint.

3.       The opposite party No.2 is a local office of National Insurance Company Ltd. at Charkhi Dadri which is OP no.1 in the complaint represented by Advocate Sh. Vinod Kumar Chahar. However, no.2&3 were proceeded against ex-parte vide order dated 12.01.2021 as none appeared on their behalf despite issuance of registered notice on 28.12.2020

4.       The complainant in support of his case has filed his affidavit Ex.CW1/A and tendered the documents Annexure C-1 to Annexure C-6 and evidence of the complainant was closed vide order dt.22.11.2021.

5.       Ld. Counsel for the OP no.1 in evidence tendered the affidavit Ex.RW1/A of Shri Rajender Sharma, Manager and tendered the document Ex.R-1 to Ex.R-40 and evidence of the OP No.1 was closed vide order dt.10.11.2022.

 6.      We have heard the arguments advanced by learned counsels for both the parties.  All the documents have been perused very carefully and minutely.

7.       While having due regards to the contentions of learned counsel for both the parties, it is observed that it is not in dispute that the complainant Sh. Ashutosh Goel was having a medi-claim policy no. 36030050170006467 under the name and style of Parivar Medi-claim policy which was valid from 22.01.2018 to 21.01.2019 with Parivar Mediclaim/cashless facility for a family comprising three persons namely Ashutosh Goel (the complainant), Anamika Goel (his wife), Sakshi (daughter) and the insured value was Rs.2 lac for which insurance premium of Rs. 4,224/- was paid. Learned counsel for complainant has argued that the daughter of the complainant (Sakshi) was admitted in Sri Bala Ji Action Medical Institute, A-4, Paschim Vihar, New Delhi on 06.12.2018 with complaint of fever, swelling and body pain. The daughter of the complainant was discharged on 09.12.2018 and total treatment expenses of Rs.51,242/- which paid to the hospital. The complainant being medi-claim holder was entitled to get the benefits of the policy. However, the same was denied by the insurance company/OP no.1 on 12.02.2019 itself on the ground pre-existing disease (Thalassemia is a genetic blood disorder). Complainant in support of his case filed document Annexure-C2 i.e. the Parivar Medi-claim insurance policy from OP no.1 (National Insurance Company Limited) for sum insured Rs.2,00,000/-. The claimant has claimed Rs.51,242/- (Annexure C-3) for treatment of her daughter by Sri Bala Ji Action Medical Institute, A-4, Paschim Vihar, New Delhi. From perusal of above facts and documents, it is observed that generally any insurance company while issuing any insurance policy to any customer does not go so deep to investigate the insured but at the time of giving its benefits, searches each and everything relating to the insured and normally rejects the claim on false and frivolous grounds only to harass the customers. Any person, who purchases the policy for his or family benefits, generally deprived of the benefits of the same. Any agent or official of insurance company at the time of issuing any policy only asks the purchaser just to sign papers to purchase the policy without telling him details of terms and conditions of the policy. Thus, there is a general practice of most of the insurance companies just to sell the policies and at the time of giving benefits, declines the same on one or the other pretext. In the instant case, the claimant is victim of such dismal and negative attitude of OPs. The policy taken by the complainant was operative since 22.01.2018 However, while settling claim dt.03.01.2019, they declined the claim on the ground quoting terms of the policy and in this case Clause 4.1 pertaining to exclusion was referred in the repudiation letter quoting- “Exclusion: 4.1 Pre-existing diseases (Thalassemia is a genetic blood disorder).”

8.       The claim of the complainant was repudiated  based on recommendations of M/s Safeway Insurance TPA Pvt. Ltd. a agency appointed by OP No.1, who was made  party to the complaint by the complainant as OP No.3. However, the said agency OP-3 preferred not to appear before this Commission and proceeded exparte vide order dated 12.01.2021.

9.       In this connection, it is worth to mention here that the disease viz. Thalassemia is stated to be hereditary but the hospital viz. Sri Balaji Action Medical Institute, A-4, Pashim Vihar, New Delhi from where treatment was taken by the complainant for his daughter has no where mentioned that the daughter was suffering from hereditary disease viz. Thalassemia. The hospital has diagnosed Anemia which is not the same as Thalassemia and Anemia is not necessarily hereditary. Thalassemia is an inherited blood disorder that causes a body to have less hemoglobin than normal. Thalassemia can cause Anemia. Thalassemia and Anemia are closely linked conditions, but they are not the same. Thalassemia is a genetic condition that damages red blood cells and anemia is a condition caused by lack of healthy red blood cells. In the absence of any expert report and not availability of hospital’s diagnosis/observation/record that the daughter was suffering from Thalassemia, the ground taken by the OP i.e. Exclusion: 4.1 Pre-existing diseases (Thalassemia is a genetic blood disorder is not acceptable and is held responsible for deficiency in service.

10.      With these observations and findings, the present complaint is allowed and the opposite party no.1 is directed to make payment of Rs.51,242/- (Fifty one thousand two hundred forty two) along-with interest @ 6% per annum from the date of filing of the complaint, Rs.3,000/- (Rs. Three thousand only) for mental agony and harassment and Rs.3,000/- (Rs. Three thousand only) as litigation expenses. The opposite party no.1 is directed to comply the order within 45 days from the date of receipt of this order, failing which OP no.1 shall pay interest of 9% from the date of filing of complaint. Copy of this order be supplied to the parties free of cost. File be consigned to record room after due compliance.