Haryana

Karnal

340/2012

Jaswant Singh Bhamba S/o Arur Singh - Complainant(s)

Versus

New India Assurance Company Limited - Opp.Party(s)

Sh.G.P. Singh

20 Oct 2016

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.

                                                              Complaint No. 340 of 2012

                                                             Date of instt. 12.07.2012

                                                               Date of decision:20.10.2016

 

Jaswant Singh Bhamba son of Shri Arur Singh resident of 55, Wazir Chand Colony, Karnal.

 

                                                                         ……..Complainant.

                                                Versus

1. New India Insurance Com. Ltd. through its Divisional Manager, G.T. Road, Karnal.

2. Raksha TPA Pvt. Ltd. SCO no.181 Sector 7C, Chandigarh through its Manager.

 

                                                                                 …………Opposite Parties.

 

                     Complaint u/s 12  of the Consumer Protection Act.

 

Before                   Sh.K.C.Sharma……….President.

                   Sh.Anil Sharma…….Member.

 

Present:-      Shri G.P. Singh Advocate for complainant.

                    Shri Parveen Daryal Advocate for opposite party no.1.

                    Representative for opposite party no.2.

                                     

 ORDER:

 

                        This complaint has been filed by the complainant u/s 12 of the Consumer protection Act, 1986, on the averments that he got himself insured with the opposite party no.1 by way of mediclaim policy. For the first time, the mediclaim policy was purchased  in the year 2003-2004, which was renewed from time to time.  The policy covered him and his wife for an amount of Rs.1,00,000/- each. No claim whatsoever was lodged by him under the policy till the year 2010. Therefore, he became entitled to bonus at the time of every renewal and at the same cost, he was offered higher amount of insurance cover. Besides that, he also used to get enhanced the amount of insurance at the time of every subsequent renewal. The policy for the year 2007-2008 provided for an enhanced insurance cover of Rs.3,00,000/- and after taking into consideration the bonus the sum insured came to Rs.3,70,000/-. The amount of insurance cover was also enhanced for Rs.3 lacs to Rs.4 lacs for the policy period of 17.10.2009 to 16.10.2010. It has further been pleaded that his wife Paramjit Kaur started suffering pain in her knees and was advised for knee replacement. Therefore, his wife was operated upon in Medanta Medicity Hospital, Gurgaon and an amount of Rs.3,63,015/- was incurred as total expenditure. However, instead of making payment of entire amount spent by him for the treatment of his wife, the opposite party no.1 paid an amount of Rs.2,60,000/- as compensation. He lodged protest and asked for payment of Rs.3,63.015/-, but his claim was repudiated by opposite party no.2, vide letter dated 1.10.2010 with the observation “The credit limit for B/L TKR is exhausted as the sum was enhanced as claim is not payable, degenerating disease for both knee TKR(Total Knee Replacement.)” The said repudiation of the claim was totally illegal and without any reasonable basis, which amounted to deficiency in service on the part of the opposite parties, due to which he suffered mental agony and unnecessary physical harassment apart from financial loss.

2.                Notice of the complaint was given to the opposite parties. Opposite party no.1  put into appearance and filed written statement controverting the claim of the complainant. Objections have been raised that the complaint is not maintainable in the present form; that the complainant has no locus standi to file the complaint; that the complaint is bad for mis-joinder and non-joinder of necessary parties; that there was no deficiency in service on the part of the opposite party no.1 and that complicated questions of law and facts are involved, which cannot be decided by this Forum in summary proceedings.

                   On merits, it has been admitted that Mediclaim policy was issued in favour of Mrs. Paramjit Kaur, the wife of the complainant and she submitted papers regarding expenditure incurred on the treatment for Knee Replacement. It has been submitted that after going through the case history, reports and bills, the cashless facility of Rs.2,60,000/- was provided to her and remaining claim was repudiated, vide letter dated 17.08.2012 as per clause 4.3 and condition no.6 of the Policy. For the previous policy the sum of insurance was enhanced from 2 lacs to 3 lacs for the year 2007-2008. The total Knee Replacement was done in the year 2009-2010, which meant that the enhanced sum insured of Rs.one lac was in the 3^rd year of inception and as per clause 4.3 the same was not payable for joint replacement surgery. Under that condition the insured was allowed sum insured of Rs.2,00,000/- and corresponding commulative bonus of Rs.60000/- i.e. Rs.2,60,000/- which was paid as cashless facility. The insured suffered from Degenerative disorder of both knees, which is a disease of chronic nature and develops gradually over years with aging. The joint replacement surgery is payable after 4 consecutive years of the policy without break. Therefore, the benefit of enhanced sum insured cannot be given to any illness which falls under the clause 4.1,4.2 and 4.3. Thus, the claim beyond Rs.2,60,000/- was rightly repudiated by the opposite parties and there was no deficiency in service on their part.

3.                Opposite party no.2 also filed written statement disputing the claim of the complainant. It has been pleaded that Mrs. Paramjait Kaur wife of complainant suffered from degenerative disease both knees. The complainant was paid Rs.2,60,000/- for degenerative disease both knees as cashless facility. The treatment of degenerative both knees was covered after four policy years, therefore, the claim was settled on the previous sum insured as per terms and conditions of the policy. Further, claim was repudiated as the limit B/L for total Knee Replacement was exhausted as enhanced sum insured was non-payable as per condition no.6 of the policy.

4.                In evidence of the complainant, his affidavit Ex.C1 and documents Ex.C2 to Ex.C17  have been tendered.

5.                On the other hand, in evidence of the opposite parties, affidavit of Rajeshwar Singh Divisional Manager Legal Ex.O1, affidavit of Amandeep Singh Ex.O2 and documents Ex.OP3 to Ex.OP6 have been tendered.

6.                We have appraised the evidence on record, the material circumstances of the case and the arguments advanced by the learned counsel for the parties.

7.                There is no dispute between the parties regarding fact that the complainant obtained mediclaim cashless facility from opposite party no.1 in the year 2003-2004. The insured sum was Rs.2,00,000/- and the policy covered him and his wife. The insurance cover was enhanced to Rs.3,00,000/- in the year 2007-2008. The wife of the complainant had undergone Knee Replacement Surgery in the year 2010 and an amount of Rs.3,63,015/- was spent for that purpose. However, the opposite parties paid an amount of Rs.2,60,000/- only and repudiated the claim for the remaining amount vide letter dated 1.10.2010 on the ground that “The credit limit for B/L TKR is exhausted as the sum was enhanced as claim is not payable, degenerating disease for both knees.”

8.                As per case of the opposite parties the initial sum insured was Rs.2,00,000/-, but the same was enhanced to Rs.3,00,000/- in the year 2007-2008. The wife of the complainant had undergone knee joint replacement surgery in the policy year 2009-2010 i.e. within the waiting period of four years of the enhanced insured amount. Therefore, as per conditions no.4.3 and 6 of the policy the enhanced insured sum could not be taken into consideration and the complainant was paid insured amount of Rs.2,00,000/-+ 60,000/- as bonus.

9.                The opposite party no.1 has produced the copy of the Mediclaim policy Ex.O6. For proper appreciation of the matter relevant portion of the conditions no.4.3 and 6 of the policy reproduced as under:-

4.3 Waiting period for specified disease/ailment/conditions

Sr. no.         Name of disease/Ailment/Surgery not covered for          Duration

22                    Joint Replacement due to Degenerative Condition                            Four years.

6.0 Renewal of Policy

          If the policy is to be renewed for enhanced sum insured then the restriction as applicable to fresh policy will apply to additional sum insured as if a separate policy has been issued for the difference. In other words, the enhanced sum insured will not be available for an illness, disease, injury already contracted under the preceding policy periods.

 

                   A bare reading of the said conditions makes it abundantly clear that if a policy is to be renewed for enhanced sum insured, then restriction as applicable to  fresh policy will apply to additional sum insured. If, a separate policy has been issued for the difference for joint replacement due to degenerative condition, the policy would not cover the enhanced sum insured for a period of four years. The complainant admittedly got enhanced the sum insured for Rs.2,00,000/- to Rs.3,00,000/-for the policy year 2007-2008. Surgery for Knee Joint Replacement of his wife was done in the policy year 2010 i.e. within three years of enhanced sum insured, whereas for joint replacement due to degenerative condition the period for claiming benefits was provided as four years under the policy. Therefore, the enhanced sum insured by the complainant could not be taken into consideration while granting the compensation to him for Knee Replacement Surgery of his wife. He was not entitled to get benefit under the policy for the enhanced insured sum of Rs.3,00,000/- was entitled to originally insured sum of Rs.2 lacs alongwith bonus. Opposite parties have also paid him the amount of Rs.2,00,000/- i.e. insured sum plus Rs.60,000/- as bonus as per the aforesaid terms and conditions of the policy. Therefore, the letter of repudiation of the claim for the remaining amount can neither be turned as illegal and nor unjustified and as such there was no deficiency in service on the part of the opposite parties.

10.              As a sequel to the foregoing reasons, we do not find any merit in the present complaint. Therefore, the same is hereby dismissed. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated: 20.10.2016

                                                                                      (K.C.Sharma)

                                                                                         President,

                                                                             District Consumer Disputes

                                                                             Redressal Forum, Karnal.

                             (Anil Sharma)

                               Member