DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, NORTH-WEST

GOVT. OF NCT OF DELHI

CSC-BLOCK-C, POCKET-C, SHALIMAR BAGH, DELHI-110088.

CC No: 673/2014

D.No._______________________                            Dated: _______________

IN THE MATTER OF:

1. NITIN GARG S/o SH. DHARAM PARKASH GARG,

2. Smt. KAMYA GARG W/o SH. NITIN GARG,

BOTH R/o A-112, ASHOK VIHAR,

PHASE-III, DELHI-110052.      … COMPLAINANT (s)

Versus

NATIONAL INSURANCE CO. LTD.,

THROUGH ITS BRANCH MANAGER,

(A. GOVT. OF INDIA UNDERTAKING),

WAZIR PUR BRANCH, MOHAN TOWER,

1^st FLOOR, COMMERCIAL COMPLEX,

RING ROAD, WAZIR PUR, DELHI-110033.                  …OPPOSITE PARTY

CORAM:SH. M.K. GUPTA, PRESIDENT

               SH. BARIQ AHMED, MEMBER

     MS. USHA KHANNA, MEMBER

                                                            Date of Institution: 06.06.2014

                                                            Date of decision: 13.12.2019

SH. M.K. GUPTA, PRESIDENT

ORDER

1.       The complainants have filed the present complaint against OP under Section 12 of the Consumer Protection Act, 1986 therebyalleging that the authorized representative of OP showed various

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          brochures, pamphlets and other literature of the Mediclaim policy and informed the complainants that the holder or beneficiary of the Mediclaim policy need not make any payment to the doctor or hospital in case of the hospitalization in a Network Hospital and that the entire expenses for such treatment of the holder or beneficiary of the Mediclaim policy shall be paid directly by the insurer to the doctor or hospital concerned and the Mediclaim policy would be a comprehensive Mediclaim policy. Thereafter, being convinced by the various representations and on the basis of the advertisements appearing in media and the complainants decided to purchase a Mediclaim Policy from OP, after necessary follow up, the complainants were issued a Mediclaim family floater policy viz. Baroda Health Policy for them and family which included their 2 children vide policy no.360803/48/11/8500005003 for the period of one year w.e.f. 21.02.2012 to 20.02.2013 for the sum assured under the said policy for the complainants of Rs.3,00,000/- and the complainants paid the premium of Rs.4,213/- to OP and during the 1^st year of the said policy there was no claim on behalf of either of the complainants or any of family members. The complainants got the said Mediclaim policy renewed for a further period of one year and the complainants paid the premium of Rs.4,647/- for the renewal of the policy and OP accepted the premium and renewed the Mediclaim Policy for the complainants and their family members and issued a fresh policy

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          no.360803/48/12/8500005299 for the period of oneyear w.e.f. 21.02.2013 to 20.02.2014. In the 1^st week of June-2013, the complainant no.-2 namely Smt. Kamya Garg suffered acute pain in abdomen and also had backache coupled with heavy bleeding during her routine menstrual periods and also felt weakness in her body and was bed ridden and as her condition did not improve, the complainant no.-2 on 07.06.2013 consulted a Gynecologist-Dr. (Smt.) Asha Gupta, MBBS, MS (Obst. & Gyn.) C/o Aditya Medical Centre, Rana Pratap Bagh, Delhi and the said doctor advised for ‘Ultrasound’ test to detect the cause for her problems and ailment and the complainant no.-2 accordingly underwent ‘ultrasound’ test and on examination of the ‘ultrasound’ test report dated 10.06.2013, it was diagnosed that the complainant no.-2 had a ‘fibroid uterus’ which needed to be removed by way of surgery in order to avoid further complications and effective treatment of her problems and ailments. The complainants further alleged that the complainant no.-2 was taken to Sunder Lal Jain Hospital, Ashok Vihar, Delhi for the requisite surgery and a pre-authorization request for cashless facility was placed by the complainants with OP which was considered by OP and an initial approval for Rs.20,000/- was sanctioned by OP for cashless treatment vide authorization no.NICDR2/76847/G-185073 dated 13.06.2013 and the complainants came to know later on that the said hospital viz.

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          Sunder Lal Jain Hospital did not has requisite and goodwill for removal of the fibroid and D & C by ‘Laparoscopic Myomectomy’. Thereafter, the complainant no.-1 decided to shift the complainant no.-2 to a Super Specialty Viz. Nova Speciality Surgery, Karol Bagh, New Delhi for the treatment/surgical removal of such fibroid and consulted a Senior Doctor Viz. Dr. Malvika Sabharwal there alongwith test reports of all previous investigations and the said doctor after perusal of the reports also advised immediate uterus surgery & D & C and she also confirmed that the said hospital viz. Nova Specialty Surgery was also registered with OP for rendering cashless facility for treatment. Thereafter, instructed her assistant doctor to record all observations in the OPD card and one assistant doctor viz. Dr. Swati while recording the clinical notes dated 13.06.2013 erroneously mentioned ‘heavy goods’ for 2 years instead of 2 months. The complainants further alleged that the ‘pre-anaesthetic evaluation’ of the complainant no.-2 was done on 15.06.2013 by the said hospital-Nova Super Speciality as a standard requirement before surgery/operation and the consulting surgeon Dr. Malvika Sabharwal checked the complainant no.-2 and evaluated all parameters and gave the date of operation i.e. 17.06.2013 and she was also prescribed certain medicines and precautions to be adopted pre-surgery by the complainant no.-2 and no previous history of any disease or like surgery was found by the said consulting surgeon. A fresh pre-authorization for cashless

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          facility was again sent to OP from there and this time cashless facility was denied vide letter no.NICDR2/76946 dated 17.06.2013 on the ground of having pre-existing disease whereas the actual disease was diagnosed/detected only on 10.06.2013 as per the ultrasound test report  and Dr. Swati on that day itself i.e. 17.06.2013 also clarified vide her letter dated 17.06.2013 that due to clerical error it was erroneously mentioned that heavy periods were 2 years instead of 2 months and it was recommended therein that the same should be considered accordingly and OP refused to give the promised cashless facility despite this clarification that complications to the patient symptoms were 2 months old and not 2 years. Thereafter, the complainants paid the hospital’s final bill dated 19.06.2013 for Rs.83,703/- out of their own pocket and by raising loan and the complainant no.-1 after seeking discharge of the complainant no.-2 from hospital, preferred a claim of the said hospital’s final bill for Rs.83,703/- with OP vide a filled up claim form and all medical documents on 24.06.2013. The complainants further alleged that the claim was repudiated by OP vide its letter bearing no. 360702/ Mediclaim/446 dated 07.08.2013 on the ground that ‘patient had a history of heavy periods for 2 years’ and the disease viz. fibroid uterus was diagnosed/detected only on 10.06.2013 as per the ultrasound test report and the treating doctor viz. Dr. Swati had already clarified that the complainants of

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          heavy periods arose 2 months ago and not 2 years i.e. during the currency of the present policy itself and the action of OP in refusing the legal claim amounts to deficiency in service on the part of OP. 

2.       On these allegations the complainants have filed the complaintpraying for direction toOP to release the claim amount i.e. Rs.83,703/- as paid by the complainants to the hospital on 19.06.2013 for hospitalization, surgery alongwith interest @ 18% p.a. till the realization, to pay Rs.12,359/- for actual reimbursable Pre & Post Hospitalization Expenses i.e. towards purchase of medicines, various prescribed tests/investigations charges, doctor’s consultation fee etc. that the complainants bore from their own pocket  as well as compensation of Rs.50,000/- for causing mental agony and harassment and also sought of Rs.15,000/- as  cost of proceeding.

3.       OP has been contesting the complaint and filed written statement. In the written statement, OP submitted that the complaint is not maintainable and is liable to be dismissed. OP further submitted that the complainants were issued a Mediclaim Policy bearing policy no. 360803/48/12/8500005299 for the period from 21.02.2013 to 20.02.2014 for a sum of Rs.3,00,000/- in the name of Sh. Nitin Garg alongwith terms & conditions of the policy and the liability of the company, if any, is subject to terms & conditions of the policy and a claim was lodged by the complainant being husband of Ms. Kamya Garg. OP further submitted that on receiving the claim OP

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          scrutinized the papers and found that the claim is not payable as per condition no.4.1 of the policy terms & conditions and as per medical record the insured was having history of heavy periods for last 2 years which means that it was pre-existing disease which is excluded under condition no.4.1 of the terms & conditions of the policy and the complete authority after applying the mind repudiated the claim and the same was informed to the complainant vide letter dated 07.08.2013 which was duly received by the complainant.

4.       The complainants filed replication and denied the submissions of the OP and furthersubmitted that OP has taken a misleading plea.

5.       In order to prove the case, the complainants filed their separate affidavits in evidence and also filed written arguments. The complainants also placed on record copy of insurance policy, copy of renewed policy, copies of the medical prescription dated 07.06.2013, 10.06.2013 and the report dated 10.06.2013 for ultrasound test, copy of Authorization for the cashless request for hospitalization under policy issued by Park Mediclaim TPA Pvt. Ltd., copy of report/OPD Assessment Form (Gyn. & Obs.) dated 13.06.2013 issued by Nova Speciality Surgery, copy of Pre-Anaesthetic Evaluation dated 15.06.2013, copy of surgeon’s prescription dated 15.06.2013, copy of denial of cashless request vide letter dated 17.06.2013, copy of Dr. Swati’s clarification letter dated 17.06.2013, copy of final bill no. KRB/IP/13/609 dated

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          19.06.2013 of Rs.83,703/- issued by Nova Speciality, copy of discharge summary pertaining to the complainant no.-2, copy of claim form, copy of repudiation letter dated 07.08.2013, copies of the 6 bills for pre-hospitalization expenses totally amounting to Rs.6,250/- and copies of the 8 bills for Post Hospitalization expenses totally amounting to Rs.6,109/-. The complainant has also placed on record copy of bills dated 13.06.2013 of Rs.150/- & Rs.2,500/- for ECG & Blood Test, Urine Test, CBC, VDRL, TSH, Sugar F, PP, Urea, Creatinine both issued by The Lab Aditya Medical Centre and receipt dated 10.06.2013 of Rs.900/- issued by Anand Imaging Centre for U/S Pelvic.

6.       On the other hand, on behalf of OP Ms. Manju Rani, Administrative Officer of OP filed affidavit in evidence.

7.       This forum has considered the case of the complainant as well asOP 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 complainant was hospitalized in Nova Speciality Hospital for the treatment of Fibroid Uterus by the procedure of Laparoscopic Myomectomy with Morcellation with intercede with D & C under GA. This fact is not disputed by OP. The sole defence taken by OP is that the complainant has concealed the material fact that she was

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          suffering from pre-existing disease for the last 2 years and as such the claim rightly repudiated by OP. This contention/defence of OP is resisted vehemently by the complainant.

8.       We have considered the point in issue. The defence of OP is negative in view of certificate dated 17.06.2013 of Dr. Swati of Nova Speciality Surgery Hospital wherein it has been certified that the patient Mrs. Kamya Garg was suffering from heavy periods since 2 months. No evidence has been lead by OP that Ms. Kamya Garg was suffering from this disease for the last about 2 years. Thus, it appears that OP has taken a false and bogus defence and in these circumstances, this Forum is of opinion that OP was not justifiedin denying the claim of the complainant.Thus, OP is held guilty of deficiency in service and unfair trade practice.

9.       Thus, holding guilty for the same, we direct OP to: -

ii) To pay to the complainants an amount of Rs.3,500/- as amounts spent on various radiological examination and pathological test

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10. The above amount shall be paid by OP to the complainantwithin 30 days from the date of receiving copy of this order failing which OP 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 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 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 13^th day of December, 2019.

BARIQ AHMED                         USHA KHANNA                         M.K. GUPTA

   (MEMBER)                               (MEMBER)                               (PRESIDENT)

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UPLOADED BY :- SATYENDRA JEET