MS. NIPUR CHANDNA, MEMBER
ORDER
23.08.2024
1. A complaint under Section 12 of Consumer Protection Act filed. In brief the facts are that complainant is the mediclaim policy holder of OP1 insurance co. vide policy bearing no. 360700/48/10/8500005522 for a sum insured of Rs. 5 Lakh w.e.f. 29.01.2013 to 28.01.2014. It is alleged by the complainant that he is the mediclaim policy holder of the OP Ins. Co. since 2009 and had renewed the policy continuously without any gap.
2. On 29.11.2013, wife of the complainant namely Mrs. Sheela Aggarwal admitted to the Fortis Hospital with the complaint of pain in stomach and lack of appetite. After thorough investigation and tests, the treating doctor come to the conclusion that she is suffering from colon cancer and as such the surgery planned and performed on 03.12.2013. The TPA of Fortis Hospital approached the Ins. Co. along with an estimate and medical record for getting approval for the surgery in question. The Ins. Co. released the adhoc payment of Rs. 1.25 Lakh against the claim in question and assured the further reimbursement of the remaining amount at the time of discharge.
3. It is alleged by the complainant that at the time of discharge Hospital again approached OP1 Ins. Co. for disbursing of the balance claim, but the Ins. Co. refused to release the claim and as such the complainant was compelled to pay the balance medical expenses from his own pocket. It is alleged by the complainant that the OP Ins. Co. rejected the claim by stating the reason that the patient was earlier detected breast cancer in 2009 as such the claim is not payable whereas the entire medical record reveals that colon cancer is not connected with the earlier breast cancer as such OP arbitrarily repudiated the balance claim. It is alleged by the complainant that he again approached the OP1 Ins. Co. for getting the reimbursement of the medical expenses on 07.02.2014 but again the OP1 Ins. Co. rejected the claim. Being aggrieved by the repudiation of the claim complainant approached this Commission for redressal of his grievance.
4. Notice of the complaint was sent to OP. OP1 filed its WS wherein it denied any deficiency in service on the part of OP. It is further stated that patient was diagnosed with CA in 2009, applicable sum insured to this illness is Rs. 2.50 Lakh, as per the policy terms and conditions 50% of the sum insured is payable per illness meaning thereby Rs. 1.25 Lakh is payable, which OP had already paid and rightly denied the non admissible claim as per policy terms and conditions. It is further stated that the claim of the complainant is rightly dealt with within the four corners of the policy terms and conditions as such repudiation is justified and legal. It is further prayed that present complaint be dismissed having no merits.
5. Rejoinder to the WS of OP filed in which the contents of the complaint are reiterated and the averments made in the WS was simply denied.
6. Complainant filed his evidence by way of affidavit wherein he has corroborated the contents of his complaint.
7. Complainant has placed on record copy of the insurance policies, copy of medical record and bill in support of his contention.
8. Ms. Manju Rani administrative officer of OP1 Ins. Co. filed her evidence by way of affidavit on behalf of OP1 Ins. Co. OP has placed on record the copy of the claim payment statement in support of its contention.
9. Despite ample opportunities no one came forward to address the arguments on behalf of parties. Case pertains to the year 2014 as such file perused and it is kept for orders.
10. The sole question for our consideration in the present complaint is that whether OP1 Ins. Co. is justified in repudiating the balance claim of the complainant.
11. Perusal of the record shows that complainant has placed on record the copies of the policy documents pertaining to the year 2012-13, 2013-14 as per which the sum insured was Rs. 4 Lakh and Rs. 5 Lakh respectively. It is admitted position that the wife of the complainant was admitted in the hospital and for her treatment complainant incurred the expenses to the tune of Rs. 6,27,494/- out of which the OP1 Ins. Co. paid a sum of Rs. 1,25,000/- and rejected the balance claim by citing the reason that as per the terms and conditions of the policy 50% of the sum insured i.e 2,50,000/- is payable per illness meaning thereby Rs. 1,25,000/- which is already paid, hence, the balance claim is rightly rejected.
12. We have carefully gone through the policy documents placed on record by the complainant. Nowhere, in the policy documents it is mentioned that 50% of the sum insured is payable per illness, moreover, the OP1 Ins. Co. while denying the balance claim has relied upon the policy terms and conditions, however, failed to place on record the same.
13. In view of the above discussion, we are of the considered opinion that the sum insured under the policy in question is Rs. 5 Lakh, OP ought to have honor the balance claim which it failed to do by citing the reason that for the present ailment the sum insured would be Rs. 2,50,000/- and they have already released Rs. 1,25,000/- as per policy terms and conditions but failed to place on record those policy terms and conditions on the basis of which the OP insurance co. consider the sum insured as 2,50,000/ and justified the rejection of the balance claim, hence, we come to the conclusion that the rejection of the balance claim by OP1 Insurance Co. is arbitrary, unjustified and illegal resulting in the deficiency in service on the part of OP1.
14. We therefore, hold OP1 guilty of deficiency in service and direct it as under:
- Pay to the complainant a sum of Rs. 3,75,000/- (5 Lakh sum insured – Rs. 1,25,000/- already paid) @ 6% p.a from the date of filing of complaint i.e. 07.04.2014 till realization.
- Pay to the complainant a sum of Rs. 20,000/- for pain and mental agony suffered by her.
- Pay to the complainant a sum of Rs. 15,000/- on account of litigation cost.
15. OP1 is directed to comply the order within 30 days from the date of receipt of this order failing which OP1 is liable to pay to the complainant interest @9% per annum from the date of non-compliance till realization.
File be consigned to record room.
16. Copy of the order be given to the parties free of cost as per order dated 04.04.2022 of Hon’ble State Commission after receiving the application from the parties in the registry. Order be uploaded on.
Announced in open Commission on 23.08.2024.
(SANJAY KUMAR) (NIPUR CHANDNA) (RAJESH)
PRESIDENT MEMBER MEMBER
