Delhi

East Delhi

CC/107/2014

SUBHASH - Complainant(s)

Versus

New india ass - Opp.Party(s)

20 Mar 2018

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.        107/2014

                                                                                                   Date of Institution               27/01/2014

                                                                                                   Order reserved on               20/03/2018        

                                                                                                   Date of Order                       23/03/2018                                                                                     

 

In matter of

Mr  Subhash Chand Gupta, adult   

R/o-B-6/12, 13, Sec. 8,  

Rohini New Delhi ………………..……..……….……………...…………….Complainant

                             

                                      Vs

 

1- M/s The New India Assurance Co. Ltd.

     DRO- II, 10^th Floor, Core I,   

     District Centre East, Laxmi Nagar, Delhi 110092

 

2-M/s The New India Assurance Co. Ltd.    

    BO- 487, 2^nd Floor, Zulfe Bengal  

    G T Road, Dilshad Garden, Delhi-110095

 

3-M/s Vipul Medcorp TPA Pvt. Ltd.

    515, Udhyog Vihar, Phase - V,

    Gurgaon, Haryana 122016………………………..……...…………....Opponents

 

Complainant’s Advocate                Mr. Sanjeev Kumar Rathi

Opponent’s  Advocate                   Mr. Izhar Ahmed 

 

Quorum   Sh Sukhdev  Singh        President

                   Dr P N Tiwari                Member

                   Mrs Harpreet Kaur      Member                                                                                             

 

Order by Dr P N Tiwari  Member

 

Brief Facts of the case                                                                                                

Complainant took Mediclaim Health Insurance Policy from OP2/ The New India assurance Co. office at Dilshad Garden, Delhi in year 2003 for a sum assured 1Lac for complainant and his wife and a sum of Rs 30,000/- for his two children and enhanced sum assured for his children to 1Lac in year 2008 to 2009. It was stated that the wife of complainant, Smt Manju Gupta was admitted in the hospital and was diagnosed a case of Left Carcinoma Breast and incurred total hospital bill of One Lac which was paid by OP.

Complainant again enhanced sum of Rs 2 Lacs for himself and for his wife from 2009 to 2010 and was paying his premium regularly up to June 2013. Complainant’s wife was again admitted in the hospital and remained admitted from 12/05/2013 to 15/05/2013 and incurred treatment bill Rs 47436/- under policy 320301/34/12/01/00000385 and all the claim papers were sent to OP3 on 22.05/2013 which was rejected on 31/07/2013 under policy terms and conditions (Anne. C2). After much perusal of his claim, OP passed a sum of Rs 20576/- and did not pay the balance amount, So complainant sent a legal notice for paying the balance amount on 01/11/2013 (Anne.C3). When no reply was received, complainant filed this complaint and claimed the balanced amount Rs 26,860/- with compensation Rs 20,000/- as harassment and litigation charges.  

OP1 filed written statement on behalf of OP2 and OP3 and denied all the facts and alleged allegations stated in the complaint though it was admitted that the said policy was issued by their OP2 branch and for Cancer Left Breast was lodged and full claim was passed where complainant and his wife had sum assured one lac. The complainant had again enhanced sum assured to two lacs in the year 2012 to 2013 and the present claim of Rs 47436/- was lodged under policy no. 320301/34/12/01/00000385. Under the policy terms and conditions, the earlier claim was paid for one lac was locked and no claim was payable for enhanced sum assured to two lacs, so was not payable.

As the present claim was for the Metastasis of Left Breast Cancer to 2^nd Left Rib and Left Hip joint as per the discharge summary which was a conservative line of treatment and insured remained for two days as indoor patient. After clarification a sum of Rs 20,576/-was paid through ECS and remaining amount of Rs 26860/ was deducted as per policy terms conditions 6(C). It was also stated that room rents were applicable to 1% of sum assured as per terms where as insured availed higher tariff of room rent (Rs 3500) for two days. After deducting extra amount of Rs 3000/- rest was paid on pro rata basis. So the paid amount after deduction was justified under the terms and conditions.  

The complainant filed rejoinder where he denied all the replies submitted in written statement of OP and claimed his claim as genuine. He also filed his evidences by way of affidavit where he affirmed on oath himself stated that his all the contents and evidence in the complaint were correct pertaining to claim year 2012 to 2013 and true to his knowledge and had been on record.

OP submitted evidences on affidavit through Mr. Shiv Dayal working as Sr. Div. Manager with OP1 and affirmed that claim under policy no. 320301/34/12/01/00000385 had sum assured two lacs in 2012 to 2013 which was enhanced in 2009 from one lac. OP had paid full amount pertaining to one lac earlier in 2006 for left breast cancer and had freezed to one lac for cancer diseases and their complications, but the present claim was reported in 2012-13 policy and had claimed Rs 47,436/- was paid a sum of Rs 20,576/- after pro-rata deduction. Hence, claimant was not entitled for the remaining amount Rs 26,860/-under policy terms and condition 6(c).

Complainant had also filed their written arguments and put other claims paid status by OP pertaining to FA 613/2014 taken on record. Arguments were heard and after perusal of file, order was reserved.

 

After perusal of all the documents on record, we have gone through terms and conditions of the policy, it is clear that OP had paid sum assured amount to one lac in the year 2006 for the same disease (Left Breast Cancer) which comes under critical diseases category. It was also seen that the sum assured one lac was freezed to the same for all future claims pertaining to the same disease or its manifestations. The present claim was reported under 2012 to 2013 policy where sum assured was two lacs as enhanced (one lac) and for enhanced sum assured amount the claim would not be payable. But OP had paid part payment as per terms of the policy 6 (c) and rest amount was deducted.

After seeing the terms 6 (c) which says that –

“if the policy is to be renewed for enhanced sum assured then the restrictions as applicable to a fresh policy will apply to the additional sum assured as if  a separate policy has been issued for the difference.  In other words, the enhanced sum assured will not be applicable for any illness, disease, injury contracted under the preceding policy periods.”

AND in pursuance to the outcome of FA 613/2014, OP had paid a sum of Rs 57,000/- and the same amount was accepted under full and final settlement. But it is not clear from the order of Hon. State Commission that under which policy OP had paid the amount. So we come to the conclusion that if OP had paid the amount in pursuance of claim falling in policy 2012-2013, complainant had no right to claim again and if the settlement claim amount pertains to some other claim for which no evidence was seen in the case, OP shall decide accordingly. Thus we dispose of this case accordingly.  

 

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

 

(Dr) P N Tiwari  Member                                                                         Mrs  Harpreet Kaur  Member                                                                                                                         

                                      

                                                  Shri  Sukhdev Singh  President