DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-II
Udyog Sadan, C-22 & 23, Qutub Institutional Area
(Behind Qutub Hotel), New Delhi- 110016
Case No.135/2014
SH. GURMEET SINGH
Resident of H-14/3,
2nd Floor, Malviya Nagar,
New Delhi-110017
….Complainant
Versus
THE MANAGER,
THE NEW INDIA ASSURANCE CO. LTD.
Branch Office 311502,
2nd Floor, Mother House,
22 Yusuf Sarai,
Commercial Complex,
Gulmohar Enclave,
New Delhi-110049
RAKSHA TPA PRIVATE LTD.
15/5 Mathura Road,
Faridabad,
Haryana
….Opposite Parties
Date of Institution : 04.04.2014
Date of Order : 12.04.2022
Coram:
Ms. Monika A Srivastava, President
Ms. Kiran Kaushal, Member
Sh. U.K. Tyagi, Member
ORDER
Member: Ms. Kiran Kaushal
1. Facts of the case as pleaded by the Complainant are that complainant is holder of a Mediclaim Policy 2007 which is a Hospitalisation Benefit Policy bearing no.311502/34/11/01/00000348 valid from 25.05.2011 to midnight of 21.05.2011 for a total sum assured at Rs.5,00,000/-.
2. It is stated that the Complainant is holder of Hospitalization Benefit policy since year 2002, which was renewed from time to time. Complainant in the year 2011 was diagnosed with knee problem and consequently approached Vedanta Hospital, Gurgaon where it was revealed that he shall require immediate knee replacement. Complainant for the said treatment, was admitted in Vedanta Hospital, Gurgaon on 05.06.2011, information of the same was given to OP-1 by the Complainant as well as by the treating hospital.
3. It is next stated that the aforesaid policy was taken as the Complainant was assured that in case any medical contingency cashless facilities shall be provided. However, OP-2 vide letter dated 03.06.2011 refused the cashless treatment of the Complainant for the following reason-
“OA both knee (as the disease falls under 4 years exclusion, cashless facility cannot be provided)”.
4. Complainant incurred expenses to the tune of Rs.4,63,022/- towards his treatment in the hospital along with Rs.50,000/- post hospitalization on medicine .Complainant submitted all the requisite documents for settlement of claim with the OPs on 08.12.2011. But the claim was not settled and the complainant was asked to submit some documents again. On the asking of OPs, Complainant again sent all the documents to OPs for perusal and settlement of the claim. Copy of the receipt via which the documents were given to OP-2 is annexed as Annexure C/11. It is also stated by the Complainant that policy of the complainant is very old which has been renewed from time to time thereto he is not covered by any exclusion clause of agreement of the mediclaim policy.
5. Aggrieved by the fact that OPs neither settled the claim of the Complainant nor did they repudiate it, the complainant approached this forum with prayer to direct OPs to pay sum of Rs.4,63,022/- towards Mediclaim and Rs.50,000/- towards post hospitalization with interest @18% per annum w.e.f 30.09.2011. Additionally it is prayed that OPs be directed to compensate the Complainant and pay Rs.10,00,000/- towards mental agony and harassment and Rs. 50,000/- towards cost of litigation.
6. OP-1 resisted the claim stating inter alia that the Complainant’s case falls within the ‘Four Year Exclusion’ Clause 4.3 read with Clause 12 of the terms and conditions of the policy, which stipulates that the cashless facility would not be available in cases of joint replacement. It is stated that the terms and conditions are available at the website of OP-1 and were also provided to the Complainant at the time of securing the said policy. The claim of the complainant is thus not payable on cashless basis by OP-1.
7. It is next stated that there is no deficiency in service or any unfair trade practice by OP-1 as the claim of the Complainant has not been repudiated but merely the cashless facility has been denied as per terms and conditions of the policy. OP-1 further states that that Complainant vide letter dated 03.06.2011 was intimated that he can send his claim and allied documents to OP-2 for settlement of the claim. However, the same has not been done till date. It is therefore prayed that the complaint be dismissed with heavy costs.
8. OP-2 filed their written version stating that the claim of the Complainant was recommended to OP-1 for repudiation as per clause 4.3 in the policy terms laid down by the OP-1. It is next stated that as OP-2 is just a third party administrator who acts as facilitator for processing the Claim as per the policy terms and condition laid down by insurance companies therefore, the name of OP-2 is liable to be deleted as it is neither a proper nor necessary party to the present complaint. Accordingly, it is prayed that the name of OP-2 should be deleted from the array of parties.
9. Complainant filed the rejoinder reiterating the averments made in the complaint. Evidence by way of affidavit and written arguments are filed on behalf of parties. Submissions made by the Complainant are heard. Material placed on record is perused.
10. Admittedly, Complainant had purchased a Mediclaim policy 2007, a Hospitalization Benefit Policy valid from 22.05.2011 to midnight of 21.05.2012 for a total sum assured at Rs.5,00,000/-
11. There are two contentions in the instant complaint. First one is that cashless facility which was promised to the Complainant at the time of taking the policy was not provided to him. Second contention of the Complainant is that the claim has neither been repudiated nor settled till filing of the complaint.
12. As regards the first contention, OP 1 in its reply has submitted that Terms and Conditions of the said policy were provided to the complainant which has not been denied by the complainant in its pleadings. Therefore the complainant is bound by the said terms. The ground for refusal of cashless facility is the Four Year Clause 4.3 read with Clause 12 of the terms and conditions of the policy reproduced below for ready reference -
4.3 WAITING PERIOD FOR SPECIFIED DISEASES/AILMENTS/CONDITIONS:
From the time inception of the cover, the policy will not cover the following disease/ailments/ conditions for the duration shown below. The exclusion will be deleted after the duration shown, provided the policy has been continuously renewed with our Company without any break.
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22 Joint Replacements due to Degenerative Condition Four years
12.0 PROCEDURE FOR AVAILING CASHLESS ACCESS SERVICE:
Claims in respect of Cashless access services will be through the agreed list of network of Hospital and is subject to pre-admission authorization. The TPA shall, upon getting the related medical information from the insured person/ network provider, verify that the person is eligible to claim under the policy and after satisfying itself will issue a pre-authorization letter/ guarantee of payment letter to the Hospital mentioning the sum guaranteed as payable also the ailment for which the person is seeking to be admitted as a patient. The TPA reserves the right to deny pre-authorization in case the insured person is unable to provide the relevant medical details as required by the TPA. The TPA will make it clear to the insured person that denial of Cashless Access is in no way construed to be denial of treatment. The insured person may obtain the treatment as per his/her treating Medical Practitioner advice and later on submit the full claim papers to the TPA for reimbursement.
13. Clause 4.3 states that this exclusion will be deleted after the duration shown, provided the policy has been continuously renewed with the company without any break. Though the Complainant has averred that since 2002 Complainant had taken hospitalization policy from OP but the same averment is not corroborated with any documentary evidence therefore, it cannot be said the Complainant had been continuously renewing the said policy with OP without any break since the last four years. Bald averments without any substantive proof has no value in the eyes of law.
14. As regards the second contention, OP-1 states that they have not denied the claim of the Complainant. OP-1 vide letter dated 03.06.2011 intimated that the Complainant can send his claim and allied documents to OP-2 for settlement . The said document annexed as Annexure C-3 shows that the complainant was asked to send the 64VB Compliance of the said policy and certificate for continuation of previous policy .Complainant states that the said documents were sent to OPs and has placed copy of receipt via which the documents were sent. We are of the opinion that receipt without the attachments/ documents does not prove anything. In the absence of any proof that the said policy is continuation of the previous policies, complainant cannot have rightful claim in view of the Four Year Exclusion Clause.
15. However, it is seen from the material placed before us that complainant provided the requisite documents to OP-1 in 2011 but OP-1 did not repudiate or settle the claim of the complainant, for non submission of documents till filing of this complaint in 2014. OP-1 cannot wait for submission of the documents till eternity. During the pendency of the complaint also no effort was made by OP-1 to decide on the admissibility of the claim. Therefore, we are of the opinion that OP-1 is guilty of deficiency in service for neither denying nor admitting the claim and for keeping the Complainant in lurch. The very purpose of taking an insurance policy is defeated if the consumer is harassed by the insurance company in this manner.
16. In view of the discussion above we hold OP -1 guilty of deficiency in service to the extent that OP-1 has failed to communicate to the Complainant as regards the admittance or repudiation of the claim. Therefore, OP-1 is directed to pay Rs 1,00,000/- towards mental agony and harassment to the complainant and also to either dispose off or settle the claim of the Complainant ,if not done already. Compliance of the directions be done within three months. Failing which OP-1 shall pay Rs 1,00,000/- @6% interest from the date of filing of the complaint till realization.
17. OP-2 is discharged of its liability as it is not a necessary or proper party to the complaint.
File be consigned to the record room after giving a copy of the order to the parties.
