DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II
Udyog Sadan, C-22 & 23, Qutub Institutional Area
(Behind Qutub Hotel), New Delhi-110016.
Case No.676/2007
Sh. Ravinder Singh
S/o Sh. Harbhajan Singh
5/23 Old Double Storey
Lajpat Nagar-4, New Delhi-110024 ….Complainant
Versus
National Insurance Company Ltd.
12, Community Centre, 3rd Floor, East of Kailash,
New Delhi-110065 ……Opposite Party
Date of Institution : 06.06.07 Date of Order : 27.04.16
Coram:
Sh. N.K. Goel, President
Ms. Naina Bakshi, Member
O R D E R
Briefly stated, the case of the Complainant is that he had a mediclaim insurance policy No.351701/48/05/8500408 dated 20.06.2005 issued by OP. The representative of the OP, after medical checkup, had renewed his mediclaim policy for the period from 20.06.2006 to 19.06.2007 for the entire family. OP issued three identity cards for his family. The OP’s agent informed him that in case he is not well, he could show the identity card in the hospital and the treatment will be cashless. On 04.12.06, he had a fever and back pain. On suggestion of local doctor he was admitted in Indrasprastha Apollo hospital on 05.12.06 with the diagnosis of diabetes (596) and he had submitted the mediclaim to the hospital authority. He was discharged from the hospital on 13.12.06. Hospital authorities stated that he had to submit the old record and the insurance company will make the payment. He made all the payments to the hospital authority on 13.12.06. He submitted all the relevant papers with the OP. On 23.03.07 he received a notice from the OP that his claim had been repudiated as his diabetes was four years old disease. According to him, he was not aware that he had diabetes and he had no symptom of diabetes. Hence, there is deficiency in service on the part of OP. The Complainant has prayed that the OP be directed to reimburse the full amount paid by him in his treatment which caused him mental agony and harassment and OP be punished accordingly for their negligence.
OP in the written statement has stated that after receipt of the claim papers from the Complainant as per terms and conditions of the policy, it was concluded that the claim was not payable as the Complainant took the policy on 20.06.2005 and later renewed on 20.06.06. On perusal of the discharge summary filed by him it was clear that he was patient of Diabetic Ketoacidosis LRTI, DM Type II since last four years. Since the policy was from 20.06.05 so this disease was pre-existing and hence the claim was not found payable as per condition No. 4.1 of the policy which was rightly repudiated vide letter dated 23.03.2007. This case can be tried before the Civil Court and Consumer Forum has no jurisdiction as the terms of the policy are a matter of contract between the parties and same are biding as per the Supreme Court judgment in United India Assurance Co. Vs. Harcharan Rai Chandan Lal 2005 ACJ 570 and National Insurance Co. Ltd. Laxmi Narain 2007 ACJ 721 wherein the Apex Court has inter-alia held that however liberally the policy may be construed, such liberalism cannot be extended to permit the substitution of words which are not intended. The Complainant’s disease was in existence since last four years and the hospital records says that the patient at the time of the admission was conscious and oriented. The Complainant was undergoing Ayurvedic treatment for the last four yeas. OP has prayed for dismissal of the complaint with cost.
Complainant has filed rejoinder to the written statement of OP.
Complainant has filed his own affidavit in evidence while affidavit of Ms. Kavita Taneja, Dy. Manager has been field in evidence on behalf of the OP.
Written arguments have been filed.
We have heard the Complainant and have also gone through the file very carefully.
It is not in dispute that the Complainant had a mediclaim policy issued by the OP w.e.f. 20.06.05 which was further renewed for the period from 20.06.2006 to 19.06.2007. The Complainant was admitted in Indraprastha Apollo Hospital on 05.12.06 and was discharged from the hospital on 13.12.06. He had informed the hospital authorities that he had a mediclaim policy issued by the OP but the hospital authority had stated that he had to make the payment and could claim the amount from the OP after discharging from the hospital. The Complainant submitted all the documents with the OP for processing his claim. The OP vide letter dated 23.03.2007 repudiated the claim of the Complainant on the ground that this disease is pre-existing and, hence, the claim was found not payable as per condition No.4.1 of the policy. The Complainant has filed copy of terms and conditions of the policy (for the purpose of identification we mark the document as Annexure-A). The Complainant has filed copy of discharge summary (for the purpose of identification we mark the document as Annexure-B).
In discharge summary, the history of the patient (complainant) has been given as under:
“Mr. Ravinder Singh Taneja, a 37 year old male has been a known case of Type 2 DM for the last 4 years on Ayurvedic treatment presented with 4 days history of fever with chills, vomiting and pain abdomen. Associated cough with scanty purulent expectoration was also present. At admission, he was found to have features of diabetic ketoacidosis with BS levels of 594 mg% and urinary ketones positive.”
He was found conscious and oriented.
The OP repudiated the claim as per clause 4.1 of the terms and conditions of the policy. Clause 4 deals with “exclusions”. It provides that:-
“4.0 – The Company shall not be liable to make any Payment under this policy in respect of any expenses whatsoever incurred by any insured Person in connection with or in respect of:
4.1 - All diseases/injuries which are pre-existing when the cover incepts for the first time.”
As per clause 4.1 the diseases which are pre-existing at the time of inception of policy for the first time are not reimbursable or payable by the OP. In this case, the OP had renewed the policy of the complainant second time. Hence, this clause 4.1 was not attracted in this case. Hence, there is a deficiency in service and unfair trade practice on the part of OP.
Copy of the bill dated 13.12.2006 is filed on the record which we mark as Mark C for the purposes of identification. This is for an amount of Rs. 56374/-.
We, therefore, allow the complaint and direct the OP to make the payment of Rs. 56374/- to the Complainant alongwith 6% interest per annum from the date of filing of complaint till the date of realization and Rs.10,000/- for harassment and mental agony undergone by the Complainant within one month from the date of receipt of copy of this order failing which the OP shall become liable to pay Rs. 56374/- along with interest @ 9% p.a. from the date of filing of the complaint till realization.
Let a copy of this order be sent to the parties as per regulation 21 of the Consumer Protection Regulations. Thereafter file be consigned to record room.
Announced on 27.04.2016
(NAINA BAKSHI) (N.K. GOEL) MEMBER PRESIDENT
Case No. 676/07
27.04.2016
Present – None.
Vide our separate order of even date pronounced, the complaint is allowed. OP is directed to make the payment of Rs. 56374/- to the Complainant alongwith 6% interest per annum from the date of filing of complaint till the date of realization and Rs.10,000/- for harassment and mental agony undergone by the Complainant within one month from the date of receipt of copy of this order failing which the OP shall become liable to pay Rs. 56374/- along with interest @ 9% p.a. from the date of filing of the complaint till realization. Let the file be consigned to record room.
(NAINA BAKSHI) (N.K. GOEL) MEMBER PRESIDENT
