Delhi

East Delhi

CC/92/2014

MANOJ KUMAR - Complainant(s)

Versus

New india ass - Opp.Party(s)

28 Apr 2017

ORDER

DISTRICT CONSUMER DISPUTE REDRESSAL FORUM (EAST)

GOVT. OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, FIRST FLOOR,

SAINI ENCLAVE, DELHI – 110 092

 

C.C. NO. 92/14

Shri MANOJ KUMAR GUPTA,

S/O Shri B.R. GUPTA,

ADDRESS: 81, BALDEV PARK,

GALI NO. 4,

1.  

                                                                                                                         ….Complainant

 

•  

 

 

THE NEW INDIA ASSURANCE CO. Ltd.,

THROUGH ITS GENERAL MANAGER,

L LEVEL-5, TOWER-ii,

JEEVAN BHARTI BUILDING,

124, CONNAUGHT CIRCUS,

1.  

 

BRANCH OFFICE: 3, ARYA SAMAJ ROAD,

                                KROL BAGH, NEW DELHI-5

                                                                                                                               ….Opponents

 

Date of Institution: 23.01.2014

Judgment Reserved for: 28.04.2017

Judgment Passed on: 09.05.2017

 

 

CORUM:

Sh. SUKHDEV SINGH                  (PRESIDENT)

Dr. P.N. TIWARI                          (MEMBER

Ms. HARPREET KAUR CHARYA (MEMBER)

 

ORDER BY: HARPREET KAUR CHARYA (MEMBER)

 

 

JUDGEMENT

 

1. Jurisdiction of this Forum has been invoked by Shri Manoj Kumar Gupta, the complainant, against New India Insurance Co. Ltd., (OP) alleging deficiency in service.
2. Facts in brief are that the complainant had taken Family Floater Medi Claim Policy with Customer ID No. 1 H 2678375 with cover for a period from 15/01/2013 to 14/01/2014 vide policy no. 31130134120300000206. The complainant was having a policy of           Rs. 1,00,000/- each for himself and his family members and w.e.f. 15/01/2012 he got family floater policy for sum of Rs. 5,00,000/-. On 07/08/2013, the complainant was admitted in Shanti Mukund Hospital and was discharged on 08/08/2013 for which his claim of Rs.18,830/- was settled for Rs.6,630/-. It is stated that on 17/09/2013 the complainant underwent heart surgery in Fortis Hospital for which bill of Rs.4,59,166/- was raised. It is further stated that the OP paid Rs.93,397/- and the balance of Rs.3,65,769/- was paid by the complainant. Despite several requests the claim of the complainant was not settled. Legal notice dated 23/12/2013 was sent to OP, which was neither complied with nor replied. Hence, the present complaint seeking order against OP to reimburse Rs.3,65,769/- along with interest @ 24% p.a., Rs.1,00,000/- as compensation for harassment, mental agony & pain, Rs.11,000/- as litigation charges & any other order. Copy of the policy for the period of 15/01/2013 to 14/01/2014, premium receipt dated 09/01/2013, Hospitalization bill, discharge summary, copy of legal notice dated 23/12/2013 are annexed with the complaint.
3. Upon service of the notice, OP filed their reply where they took the plea that the claim of the complainant was rejected as per Clause 4.1, under exclusion clause as per the discharge summary, the complainant suffered from Hypertension, which fell within first two years exclusion clause under the policy. Payment of Rs.92,397/- to the complainant was admitted. Rest of the contents of the complaint was not admitted. Policy terms & conditions, Letter dated 28/02/2014 in the form of reply and discharge summary have been annexed with their reply.
4. Evidence by way of affidavit was filed on behalf of the complainant, who examined, Sh. Manoj Kumar Gupta, the complainant himself and stated the contents of the complaint and relied on Ex CW1/1- copy of the policy, Ex CW1/2 and Ex CW1/3 are Bill and Discharge summary respectively, copy of notice and speed post receipt are exhibited as Ex CW1/4 & Ex CW1/5, Letters written to the hospital are Ex CW1/6 to Ex CW1/9. However, OP did not file their evidence despite opportunity.
5. We have heard the submissions on behalf of the Ld. Counsel for the complainant, OP did not appear despite service of notice. We have perused the material placed on record. The complainant has received Rs.93,397/- from OP is an admitted fact. Discharge summary bears Hypertension and D M-II in past history. As the complainant has got the cover enhanced from Rs.1,00,000/-  to Rs.5,00,000/- his claim was rejected under exclusion clause relating to pre-existing disease. The claim of the complainant has been rejected under clause 4.1 and clause 4.3 of the terms & conditions careful reading of Clause 4.1 reveals that pre-existing diseases are excluded, the said exclusion will be deleted after four consecutive claim free policy year “All diseases/injuries/conditions, which are pre-existing when the cover incepts for the first time (except as shown hereunder). Any complication arising from pre-existing disease/ailment/injury will be considered as a part of pre-existing condition. This exclusion will be deleted after four consecutive claim free policy year provided there was no hospitalization for the pre-existing disease/ailment/condition/injury during the said four years of insurance with our company”. OP has not filed any document to prove that the complainant was suffering from Hypertension at the time of inception of the policy. Considering             clause 4.3 “From the time of inception of the cover, the policy will not cover the following diseases/ailments/conditions for the duration shown below. This exclusion will be deleted after the duration shown, provided the policy has been continuously renewed with our company without any break, serial no. 11- Hypertension- Two years, which deals with waiting period for specified diseases/ailments/conditions which bears that Hypertension was not covered for 2 years from the time of inception of the cover. As per letter dated 31/10/2013 written by the complainant himself that he was not suffering from Hypertension, further in policy document, the date of proposal has been written as 15/01/2013. As, Hypertension is excluded for two years under clause 4.3 of the policy terms & conditions. The OP has rightly settled the claim of the complainant under individual policy and rejected the claim under Family Floater Medi Claim Policy as it is hit by Clause 4.3 Policy Terms & Conditions. Thus, no deficiency in services can be attributed on the part of OP. Hence, the present complaint is dismissed without orders to cost.

Copy of this order be sent to both the parties as per law.

 

 

 

(Dr. P.N. TIWARI)                                                                    (HARPREET KAUR CHARYA)              

      MEMBER                                                                                                MEMBER

 

                                                 (SUKHDEV SINGH)

                                                     PRESIDENT