Delhi

East Delhi

CC/338/2016

DINESH CHANDER - Complainant(s)

Versus

NEW INDIA ASS. - Opp.Party(s)

03 Mar 2020

ORDER

DISTRICT CONSUMER DISPUTE REDRESSAL FORUM, EAST, Govt of NCT of Delhi

 CONVENIENT SHOPPING CENTRE, 1^st FLOOR, SAINI ENCLAVE, DELHI 110092  

 

                                                                                                   Consumer Complaint no.       338/2016

                                                                                                   Date of Institution               05/07/2016

                                                                                                   Order reserved on               03/03/2020

                                                                                                   Date of Order                       06/03/2020

 

In matter of

Mr Dinesh Chand Mathur

s/o- Late Sh Genda Lal Mathur

&

Mrs Beena Mathur

w/o Dinesh Chand Mathur

R/o Plot no. 546, Flat no 203

Niti Khand -1, Indira Puram, Ghaziabad, 201014 ..…………….Complainant

 

                                                                             Vs

The Sr. Manager,

The New India Assurance Co. Ltd

RO- 10^th Floor, Core I

Scope Minar, Laxmi Nagar District Centre

Delhi 110092 …………………………………....……………..….…………..Opponent

 

Complainant’s Advocate                Mr D K Singh, Ms Shushma Goyal & Asso.

Opponent’s Advocate                    Mr Arvind Kumar

 

Quorum   Sukhdev  Singh        President

                   Dr P N Tiwari                Member

Mrs Harpreet Kaur       Member

 

Order by Dr P N Tiwari Member 

 

Brief -

Complainant / Policy holder had filed this complaint u/s 12 of the Consumer Protection Act, 1986 for deficiency in service of OP for nonpayment of hospital bills of insured from 2008 to 2017 under CASH LESS mediclaim policy by OP.

Facts of the case-Complainant had a Good Health mediclaim policy vide policy certificate no. EGH-FEB 1000343 having tenure from 01/02/2010 to 31/01/2011 for sum assured 01 lakh for himself and his wife (Ex CW1/1) with TPA.

The said policy was renewed again up to 31/01/2012 with certificate no EGH – FEB 1100652 (Ex CW1/2). It was stated that complainant took hospital benefit mediclaim policy 2007 w.e.f. 25/02/2013 to 24/02/2014 having policy no.32310034120100000758 for sum insured one lakh with terms and conditions (Ex CW1/3). The same policy was renewed from 25/02/2014 to 24/02/2015 under 2012 schedule (Ex CW1/4) and further policy was renewed up to 24/02/2017 (Ex CW1/5&6).

It was stated that wife of complainant/Smt Beena Mathur applied for cashless for getting operated for Left eye Cataract from 23/11/2011 to 24/11/2011 to TTK TPA on 02/11/2011 with package charges Rs 34,000/-which was denied to the treating hospital with reason of “DM, HTN and Hypothyroidism were present since 5 years” and policy was in 3^rd years, so amounts nondisclosure of facts. After getting operated for Cataract, applied post hospitalization expenditures of Rs 14,000/- and 10,000/, but this amount too was not paid.

Complainant’s wife again send cashless for Cataract / eye treatment on 19/02/2016 which was scheduled for 23/02/2016 and estimate was given for Rs 21380/-from Sharp Sight Centre, Preet Vihar, Delhi which too was denied (CW1/8, 9, 10A). It was stated that total amount Rs 46803/- were paid for the treatment from 01/02/2008 to 24/02/2017. When no claim was considered, complainant sent legal notice on 28/03/2016 (Ex CW1/11), but neither reply of notice was given nor claim was passed, so filed this complaint and claimed total sum of Rs 53,242/-paid on different dates with damages Rs 2 lakhs for deterioration of 90% vision in both eyes and Rs 50,000/-compensation for harassment, mental agony and Rs 10,000/- as litigation charges.

 

OP in their written statement denied all the allegations of deficiency in services in denying cashless approval. It was submitted that complainant had submitted policy from 2009 and up to 2010 as Good Health Policy Certificate and after that took Individual mediclaim policy schedule 2007 and 2012 with sum insured 01 lakh. It was also submitted that cashless was deniedsince beginning based on treating doctor’s certificate, but complainant had never applied for final claim under claim policy. As far as Pre-existing ailments as DM,HTN and Hypothyroidism was concerned, OP could had reviewed the tenure of continuity of policy, but in absence of required documents for getting claim reviewed, complainant had to submit treatment documents as per policy terms and conditions. Here complainant claimed treatment expenditures from 2008 to 2017 pertaining to cashless which could not be processed. Hence, cashless was rightly denied for the hospital. As far as diagnosed ailment was not Cataract, but it was Proliferative Diabetic Retinopathy which was an advanced complication of DM and the same was present prior to the inception of policy. The treatment documents were also not submitted in time correctly. As per the terms and conditions of the policy were concerned (Ex OPW1/1), policy seeker/insured was bound by the signed declaration under policy proposal form and all terms were binding as per the table under condition 4.3 where certain ailments/diseases had fixed limitation / waiting period. The diagnosed complication of DM had two years waiting period as under this case, Diabetic Retinopathy was present in both the eyes and complainant’s wife had to undergo intra-ocular injection of drugs number of times, but emphasis was put on Cataract operation which was wrong. Hence there was no deficiency in services by OP and as there was no cause of action ever arisen, so complaint could not accepted and so complaint be dismissed.

 

Before submitting rejoinder, sought transferring the case to National Lok Adalat (Ex CW1/12), but could not be settled. So complainant filed rejoinder to written statement where he denied all the replies of OP and stressed on cashless payment every times, but OP always denied claim which was sent by the treating doctor from hospital.Complainant through his affidavit filed evidences where he affirmed that all the facts were correct and true as per his complaint as correct and true and on record. He relied upon all evidences of cashless requests sent to OP time to time and legal notice was too sent, but OP neither replied to legal notice nor considered claim.

OP did not file evidences despite of serving notices so right to file evidences were closed from 08/05/2018.

Complainant submitted his written arguments/submissions containing certain citations applicable to his case where OP was directed to consider claim of petitioner/complainant. The citations were as under-

1. Ravi Goyal vs UIIC Ltd, 2017
2. Hari Om Aggarwal vs OIC Ltd.,
3. NIAC vs Vishwanath Manglunia, 2006, 3,CPJ 68,
4. Lalita N Shetty vs Star Health Allied Insurance Co., 2008 CTJ 347,
5. Usha Aggarwal vs ICICI Lumbard,
6. NIC vs Mrs Krishna Avatar Aggarwal
7. Aviva Life Insurance vs Sharanjit Kaur,
8. Satish Kumar Kathuria vs NIC,
9. LIC of India vs G M Channabasamma,
10. Pradeep Kumar Garg vs NIC,
11. Manivasagam vs NIC, Madras HC in WA no. 956/2011,
12. NIC vs VL Jain, DSDRC Del,
13. Ravi Goyal vs UIIC Ltd.
14. Rajesh Rana & others vs Apollo Munich Health Insurance Co., CHD SCDRC
15. SBI General Insurance Co. Ltd vs Balwinder Singh Jolly, Appeal no. 278/2016 CHD SCDRC
16. PNB Met Life Insurance Co. Ltd vs Sunita Goyal, RP 1729/2016, NC

And few more citations were mentioned by the complainant. After scrutiny of all above citations, it was observed that complainant/appellant was directed to file final claim for the consideration of payment, but in all above citations, complainant approached redressal bodies from State Commissions, National Commission and before Hob. High Courts which showed that complainant, in above references, was totally un-aware of claim procedure. Here in this case also complainant did not approach OP in time schedule for filing his final claim before the OP.

Arguments were heard from the complainant counsel who stressed on paying his claim amount. After perusing material and evidences on record, order was reserved.

 

After seeing entire facts and evidences on record and properly analyzing medical facts, it was seen whether complainant had right to claim based on Cashless requests sent from treating hospital. Even denying cashless does not mean that right to file final claim with OP was closed ever by OP. hence when no cause of action ever occurred in favour of complainant, his complaint cannot be considered.

 

So in absence of cause of action, no deficiency or liability of OP could be fixed on OP as this complaint is a pre matured one. Hence, complaint is dismissed without any order to cost.

Copy of this order be sent to the parties as per the Section 18 (6) of the Consumer Protection Regulations,2005 (in short CPR) and file be consigned to Record Room under Section 20(1) of the CPR.

 

(Dr) P N Tiwari  Member                                                                     Mrs Harpreet Kaur Member

 

Sukhdev Singh  President