DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, NORTH-WEST
GOVT. OF NCT OF DELHI
CSC-BLOCK-C, POCKET-C, SHALIMAR BAGH, DELHI-110088.
CC No: 907/2016
D.No._______________________ Dated: _______________
IN THE MATTER OF:
PRATAP SINGH,
S/o LATE S. PRITAM SINGH,
R/o H. No. B-97, 1st FLOOR,
TAGORE GARDEN EXTN.,
DELHI-110027. … COMPLAINANT
Versus
1. NATIONAL INSURANCE CO. LTD.,
BJ-88, NEAR SHALIMAR BAGH CLUB,
EAST SHALIMAR BAGH,
SHALIMAR BAGH, DELHI-110088.
ALSO AT: BRANCH OFFICE: 350201,
3rd FLOOR, DEEN DAYAL UPADHYAYA BHAWAN,
7-E, JHANDEWALAN, NEW DELHI-110055.
2. MEDI ASSIST INDIA TPA PVT. LTD.,
B-20, SECTOR-2, NOIDA, U.P.-201301. …OPPOSITE PARTY (ies)
CORAM:SH. M.K. GUPTA, PRESIDENT
SH. BARIQ AHMED, MEMBER
MS. USHA KHANNA, MEMBER
Date of Institution: 15.09.2016
Date of decision: 08.06.2020
SH. M.K. GUPTA, PRESIDENT
ORDER
1. The complainant has filed the present complaint against OPs under Section 12 of the Consumer Protection Act, 1986 thereby alleging that the complainant was approached by OP-1 & OP-2 in
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connection with medical policy in the year-2007 and after long discussion and persuation by OPs, the complainant agreed to buy a medical policy i.e. Parivar Mediclaim policy vide policy no. 350201/48/07/8500003157 dated 10.10.2007 and is continuing to buy medical policy from OP-1 every year till date vide policies nos. 350201/48/08/8500003222 w.e.f. 10.10.2008 to 09.10.2009, policy no. 350201/48/09/8500003558 w.e.f. 10.10.2009 to 09.10.2010, policy no. 350201/48/10/8500003803 w.e.f. 10.10.2010 to 09.10.2011, policy no. 350201/48/11/8500004017 w.e.f. 10.10.2011 to 09.10.2012, policy no. 350201/48/12/8500004801 w.e.f. 10.11.2012 to 09.10.2013, policy no. 350201/48/13/850000 4802 w.e.f. 11.11.2013 to 10.11.2014, policy no. 350201/48/14/ 8500004372 w.e.f. 11.11.2014 to 10.11.2015 and policy no. 350201/48/15/8500004209 w.e.f. 11.11.2015 to 10.11.2016 and the complainant was regular in making payment of premium and never claimed under the policies till date except the 2 claims in question. The complainant further alleged that the complainant fell ill and treated by Sri Balaji Action Medical Institute and Fortis Escorts Heart Institute & Research Centre Ltd. New Delhi who were informed at the initial stage about the medical policy of the complainant who promised to provide cashless services, meaning thereby the said hospitals were supposed to get the bills re-imburshed from OP-1 but OPs did not honour their promise and refused for the same later and asked the complainant
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to pay them directly for the treatment which the complainant did. Thereafter, filing the claim forms vide claim nos. 10297517 for Rs.68,048/- & no.11360472 for Rs.4,43,570/- and fulfilling all the formalities required by OP-1 & OP-2 to the satisfaction, made several personal visits and requests but in vain and OPs asked the complainant to fulfill certain formalities at different occasions which the complainant did to the satisfaction of OPs without delay and the complainant was made to wait a long and his claims were never processed. On 08.01.2014, the complainant received a letter from OP-1 wherein it was informed by OP-1 that the claim no.10297517 for Rs.65,120/- has been approved and is on hold for payment because another claim is in process and it was further assured by OP-1 that the funds will be transferred when another claim will be processed. Thereafter, nothing has been received from OPs, nor any communication in this regard was made by OPs and disappointed from the callous and cold attitude of OP-1, the complainant made a complaint to IRDA on 18.01.2016 in this regard from where the complainant got response from OP-1 on 18.02.2016 wherein OP-1 refused to process the claims on the ground that there was gap in the policy due to dishonor of cheque for insufficiency of funds and however, the policy is continuing as soon as the cheque was dishonoured, cash was tendered by the complainant and accepted by OP-1 and the policy was continued and therefore, the ground of rejection of claim taken by OP-1 is
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arbitrary and is not correct. The complainant further alleged that the complainant has checked the status of his both the claims and the claims status shown at the website of OP-1 is in progress and has not been closed and there is no reason mentioned for denial and upon being disappointed from the indifferent and callous response and attitude of OPs, no other option is left to the complainant except to resort to legal means of recovery of the said amount, thus the present complaint and the action of OPs in refusing the legal claim amounts to deficiency in service on the part of OPs.
2. On these allegations the complainant has filed the complaint praying for direction to OPs to pay a sum of Rs.4,43,570/- plus Rs.64,048/- respectively (total Rs.5,11,618/-) to the complainant alongwith interest @ 24% p.a. till its realization as well as compensation of Rs.2,00,000/- for causing mental agony and harassment and also sought Rs.40,000/- towards cost of litigation.
3. Only OP-1 has been contesting the complaint and filed reply. In the reply, OP-1 submitted that the complaint is not maintainable and is liable to be dismissed in view of the fact that the policy for the period from 10.11.2011 to 09.11.2012 was issued after a gap of 31 days because the cheque for the premium amount got dishonoured and the policy deems to be issued on 10.11.2011 and the waiver of the gap is not allowed/permissible in the case where the premium for the policy could not be paid owing to dishonor of the cheque and
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the policy of the above said period is a fresh one and hence, the ailment for which the claims have been preferred fall in the category of pre-existing disease which is not payable. OP-1 further submitted that there is no cause of action against OPs and the present complaint is liable to be dismissed for want of cause of action and the insurance policy containing the terms & conditions is a contract between the complainant and OP and the terms & conditions therein has to be followed strictly by both of the parties and any violation in respect thereof deserves the complaint to be dismissed with exemplary costs. OP-1 further submitted that the assessment and payment of claim is always subject to terms & conditions of the policy and any deviation or violation in respect thereof makes the claim redundant and the complainant fails to fulfill the required conditions of the insurance policy. OP-1 further submitted that the policy of the complainant was continuing and owing to the dishonor of the cheque, there was gap in the policy which made the ailments pre-existing which is not payable and OP is not liable to pay Rs.2,00,000/- to the complainant for breach of trust and deficiency in service.
4. The complainant filed replication/rejoinder and denied the submissions of the OP-1 and further submitted that OP-1 has taken a misleading plea.The complainant submitted that OP-2 who is the agent of OP-1 vide his letter dated 08.01.2014 has stated that
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claim no. 10297517 is approved of Rs.65,120/- and the said amount is in hold because of processing of 2nd claim and funds will be transferred thereafter.
5. In order to prove his case, the complainant filed his affidavit in evidence and also filed written arguments. The complainant also placed on record copies of insurance policy no.350201/48/07/85 00003157 for the period from 10.10.2007 to 09.10.2008 (mid-night), no.350201/48/08/8500003222 w.e.f. 10.10.2008 to 09.10.2009, no.350201/48/09/8500003558 w.e.f. 10.10.2009 to 09.10.2010, no.350201/48/10/8500003803 w.e.f. 10.10.2010 to 09.10.2011, no.350201/48/11/8500004017 w.e.f. 10.11.2011 to 09.11.2012, no.350201/48/12/8500004801 w.e.f. 10.11.2012 to 09.11.2013, no.350201/48/13/8500004802 w.e.f. 11.11.2013 to 10.11.2014, no.350201/48/14/8500004372 w.e.f. 11.11.2014 to 10.11.2015, no.350201/48/15/8500004209 w.e.f. 11.11.2015 to 10.11.2016, copy of repudiation letter dated 03.11.2014 issued by OP-2, copy of letter dated 08.11.2014 regarding claim under policy no.350201/48/11/8500004017 reference no. 10297517 MAID: 5004353723, copy of final bill no. 12001136 dated 19.04.2012 of Rs.68,048/- issued by Sri Balaji Action Medical Institute, Paschim Vihar, New Delhi, copy of bill no.12/MBB2-H10258/Ca/IH004085 Bill dated 06.09.2012 of Rs.4,43570/- issued by Fortis Escorts, New Delhi, copy of bill details no. 12/MBB2-H10258/Ca/IH004085 dated 06.09.2012 issued by Fortis Escorts, New Delhi, copies of
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claim forms, copy of sum insured details, copy of schedule of expenses incurred by the claimant, copy of letter dated 08.01.2014 sent by OP-2 to the complainant regarding information about approval of Rs.65,120/- in respect of claim 10297517, copies of letters dated 04.08.2014 regarding authorization to M/s Medi Assist India Pvt. Ltd. and copy of discharge summary issued by Fortis Escorts, New Delhi.
6. On the other hand, Sh. Sandeep Goel, Divisional Manager of OP-1 filed his affidavit in evidence. OP-1 also placed on record copy of terms & conditions of the policy. OP-1 also filed written arguments.
7. This forum has considered the case of the complainant as well as OP-1 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 Sri Balaji Action Medical Institute, Paschim Vihar, New Delhion 12.04.2012 and was discharged on 19.04.2012for treatment of Cerebrovascular Accident (CAV) and again admitted on 27.08.2012 in Fortis Escorts Heart Institute & Research Centre Ltd., New Delhi and was discharged on 06.09.2012 for treatment of Rheaumatic Heart Disease (RHD) with MS & MR with Left Ventricular Dysfunction (LVD).From the letter dated 08.01.2014 of OP-2 who is the agent of OP-1 it is also proved that an amount of Rs.65,120/- of claim
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10297517 has been approved and these facts are not disputed by OP-1. The sole defence taken by OP-1 is that the complainant was suffering from pre-existing disease and that the policy for the period from 10.11.2011 to 09.11.2012 was issued after a gap of 31 days because the cheque for the premium amount got dishonoured and the waiver of the gap is not allowed/permissible in the case where the premium for the policy could not be paid.
8. We have considered the defence taken by OP-1 in the light of pleadings, evidence and documents proved on record. OP-1 has already approved an amount of Rs.65,120/- with respect to claim 10297517. Regarding 2nd claim of the complainant is concerned it cannot be said that the complainant was having the prior knowledge that he will suffer which such ailment in future. Moreover, OP-1 has not lead any evidence to show that the complainant was suffering from a pre-existing disease. Thus, it appears that OP-1 has taken a false and bogus defence and in these circumstances, this Forum is of opinion that OP-1 was not justified in denying the claim of the complainant. Thus, OP-1 is held guilty of deficiency in service and unfair trade practice.
9. Thus, holding guilty for the same, we direct OP-1 to: -
i)To pay to the complainant an amount of Rs.3,00,000/- i.e. the sum assured as per the policyout of the amount paid by the complainant to the hospital for the treatment/surgery/ hospitalization expenses.
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ii) To pay to the complainant an amount of Rs.50,000/- as compensation for causing harassment and mental agony.
iii)To pay to the complainant an amount of Rs.10,000/- towards cost of litigation.
10. The above amount shall be paid by OP-1 to the complainant within 30 days from the date of receiving copy of this order failing which OP-1 shall be liable to pay interest on the entire awarded amount @ 10% per annum from the date of receiving copy of this order till the date of payment. If OP-1 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 25/27 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 8th day of June, 2020.
BARIQ AHMED USHA KHANNA M.K. GUPTA
(MEMBER) (MEMBER) (PRESIDENT)
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UPLOADED BY SATYENDRA JEET
