Haryana

Karnal

173/2014

sandhya Goel W/o Rajesh Goel - Complainant(s)

Versus

National Insurance Company Ltd - Opp.Party(s)

Vishal Goel

13 Feb 2017

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.

                                                              Complaint No. 173 of 2014

                                                             Date of instt.03.06.2014

                                                                Date of decision:13.2.2017

 

Sandhya Goel wife of Shri Rajesh Goel, resident of House no.7, Club Lane, Karnal.

 

                                                                   ……..Complainant.

                                                Versus

1. Divisional Manager, National Insurance Company Ltd., Dhanwant Building, G.T. Road, opposite Bus Stand, Karnal.

2. Managing Director, National Insurance Company Ltd., Regd. Office 3, Middleton street, Post Box no.9229, Kolkatta.

3. M/s Medsave TPA, SCO 121-122-123, Second Floor, Sector-34/A, Chandigarh.

4. Chief Operating Officer, Medsave healthcare(TPA) Ltd. F-701/A, Ladu Sari, Mehrauli, New Delhi.

 

                                                                   ………… Opposite Parties.

 

                     Complaint u/s 12  of the Consumer Protection Act.

 

Before                   Sh.K.C.Sharma……….President.

                   Sh.Anil Sharma…….Member.

 

Present:-      Sh. Vishal Goel Advocate for the complainant.

                    Sh. Sanjeev Vohra Advocate for the Opposite parties.

                  

 ORDER:

 

                        This complaint has been filed by the complainant u/s 12 of the Consumer protection Act, 1986, on the averments that she obtained mediclaim policy bearing no.420501/48/13/8500000254, valid from 8.10.2013 to 7.10.2014 from opposite party no.1. She and her husband Shri Rajesh Goel were covered under the said policy. On 1.11.2013 she was having fever, Dengue fever was at peak in those days, therefore, she got her blood tested from Dr. Yogesh Chhabra, Karnal and Dengue was found. On 2.11.2013, her condition became more severe, therefore, she again got tested her blood and as per report platelet count came down to 36000/cmm. Due to her severe condition, she was got admitted in Kamal Hospital, Kushambi, Gaziabad, where she remained admitted from 2.11.2013 to 7.11.2013. She spent an amount of Rs.58,837/- on the treatment. She submitted form for cashless hospitalization on the day she was admitted, but the cashless was denied by the opposite party no.3, vide letter dated 5.11.2013 by taking plea of 4.2 clause of policy “Illness falls within 30 days of policy inception”. After discharge from the hospital, she submitted the genuine claim of expenses incurred on her treatment alongwith all the original documents, with the opposite party no.4, who was acting as TPA for opposite parties no.1 and 2, vide letter dated 11.11.2013. On checking the status of her claim on the website of opposite parties no.3 and 4, it was found that the claim was rejected, but no reason was given for rejection of the same. Thereafter, she wrote letter dated 31.12.2013 to opposite party no.1, but to no response. She again sent reminder dated 3.1.2014 to opposite party. Her husband sent letter dated 16.5.2014 to Regional Claims Review Committee at Regional Office for review of the decision of the committee in respect of repudiation of claim, but vide reply dated 5.6.2014 the Regional Claims Review Committee informed that the claim was not maintainable and there was no change in the decision. The Dengue was due to Mosquito bite, which is covered by the word “Accident,” but the opposite parties illegally repudiated the claim, which amounted to deficiency in service, due to which she suffered mental pain and agony apart from financial loss.

2.                Notice of the complaint was given to the opposite parties. Opposite parties no.1 and 2 put into appearance and filed written statement controverting the claim of the complainant. Objections have been raised that the complaint is not maintainable in the present form and that the complainant has not approached this forum with clean hands.

                   On merits, it has been submitted that the claim of the complainant was repudiated as per 4.2 clause of the terms and conditions of the policy, according to which “Any disease contracted by the insured person during the first 30 days from the inception of the first policy. This shall not apply in case the insured person is hospitalized for injuries, suffered in an accident which occurred after inception of the first policy.” It was fresh policy and the date of inception of the policy 8.10.2013. TPA received cashless request on 2.11.2013 i.e. within 30 days from the inception date. Therefore, claim was not admissible and was rightly repudiated by the opposite parties and duly conveyed to the complainant.

3.                None put into appearance on behalf of opposite parties no.3 and 4 despite service, therefore, exparte proceedings were initiated against them, vide order dated 31.3.2015.

4.                In evidence of the complainant, her affidavit Ex. CW1/A and documents Ex.C1 to C24 have been tendered.

5.                On the other hand, in evidence of the opposite parties no.1 and 2, affidavit of Yashpal Assistant Manager Ex.O1 and documents Ex.O1 to Ex.O5  have been tendered.

6.                We have appraised the evidence on record, the material circumstances of the case and the arguments advanced by the learned counsel for the parties.

7.                There is no dispute that the complainant had obtained mediclaim policy from opposite party no.1, which was valid for the period of 8.10.2013 to 7.10.2014. She was having fever on 1.11.2013, therefore, she got tested her blood on 1.11.2013 and again on 2.11.2013. Her platelet count had gone down to 36000/cmm. Therefore, she was admitted in Kamal Hospital, Kushambi, Gaziabad on 2.11.2013 and was discharged on 7.11.2013. She lodged claim for Rs.58837/- spent by her on her treatment. The opposite parties repudiated the claim, vide letter dated 16.5.2014, the copy of which is Ex.O2, on the ground that the policy inception date was 8.10.2013 and TPA received cashless request on 2.11.2013 within 30 days from the inception date, therefore, the claim was not admissible as per clause 4.2(b) of policy terms and conditions. Policy condition no.4.2 was reproduced in the letter of opposite parties, the copy of which is Ex.O4 and the same is reproduced as under:

          “Any disease contracted by the insured person during the first 30 days from the inception of the first policy. This shall not apply in case the insured person is hospitalized for injuries, suffered in an accident which occurred after inception of the first policy.”

 

8.                Learned counsel for the opposite parties put a great thrust upon the contention that Dengue is a disease and it cannot be said by any stretch of imagination that the complainant suffered the disease of Dengue due to accident, therefore, her claim was rightly repudiated under clause 4.2 of the policy.

                   In support of his contention, he relied upon SBI Life Insurance Co. Ltd. Versus Kamaljeet Kaur and Anr. 2016(1) CLT page 285 wherein the insured died due to “Acute MI” during first 45 days from the date of commencement of the policy. The question arose whether death caused by “Acute MI” can be treated as death due to accident. Under those circumstances, it was held by Hon’ble National Commission that death due to “Acute MI” may be called an accidental death, but it is definitely not a death due to accident, therefore, insurance company is not liable.

9.                To wriggle out the aforesaid contention, learned counsel for the complainant vehemently argued that the complainant suffered Dengue due to Mosquito bite, which certainly falls in the category of accident. In this regard he sought sustenance from National Insurance Co. Ltd. Versus Mousumi Bhattacharjee & Ors. 2016 (4) CPJ 438  wherein the insured suffered from Malaria due to Mosquito bite and as a result of the same, he died. The claim was repudiated by the insurance company on the ground that Mosquito bite was a disease not an accident. In view of such facts and circumstances, it was held by the Hon’ble National Commission that an accident is something that happens unexpectedly and was not planned in advance. Mosquito bite is something which no one expects and which happens all of a sudden without any act or omission on the part of victim. Therefore, death due to mosquito bite is death due to an accident.

11.              In the instant case, the complainant suffered Dengue and this problem happens due to mosquito bite. Therefore, it cannot be considered as a disease, but it is an injury due to accident in view of law laid down by the Hon’ble National Commission in Mousumi Bhattacharjee’s case (supra). The clause 4.2 of the condition does not apply in case of the insured person is hospitalized for injury suffered in accident, which occurred after inception of the policy. Therefore, under such facts and circumstances, the complainant who suffered from Dengue on account of mosquito bite within 30 days from the inception of the policy, is certainly entitled to get compensation and her case is covered under the exclusion part of 4.2 of the policy. Thus, the repudiation of the claim of the complainant by the opposite parties was not legally justified, therefore, the same amounted to deficiency in service.

12.              The complainant has claimed an amount of Rs.58837/- as the expenses incurred by her for her treatment. The pre-hospitalization bills regarding tests got conducted by her are not payable. The hospital bill is of Rs.36,560/-, the copy of which is Ex.C3. The pharmacist bills are of Rs.4577/-, the copies of which are Ex.C16 to C23 apart from that the plateletpheresis  had to be purchased for Rs.15,500/- from Pushpanjali Crosslay Hospital vide bill, the copy of which is Ex.C24. Thus the total amount comes to Rs.36,560+15,500+4577=56,637/-.

13.              At this stage learned counsel for the opposite parties pointed out that as per terms and conditions of the policy out of the hospitalization bills some amounts, which are not covered under the policy, are to be deducted.

14.               As a sequel to the foregoing discussion, we accept the present complaint and direct the opposite parties to pay the amount of Rs.56,637/-minus the amount which is not admissible as per terms and conditions of the policy to the complainant  alongwith interest thereon @ 9% per annum from the date of filing of complaint till its realization. We further direct the opposite parties to pay Rs.5500/- to the complainant on account of mental agony and harassment suffered by her and for the litigation expenses. This order shall be complied within 30 days from the receipt of copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated: 13.2.2017

                                                                                      (K.C.Sharma)

                                                                                         President,

                                                                             District Consumer Disputes

                                                                             Redressal Forum, Karnal.

                             (Anil Sharma)

                               Member