BEFORE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SAHIBZADA AJIT SINGH NAGAR (MOHALI)
Consumer Complaint No.640 of 2014
Date of institution: 04.11.2014
Date of Decision: 18.04.2016
Ajay Kumar Misra son of S.B. Misra, resident of House No.347, Phase-III, Housing Board Colony, Sai Road, Baddi, Himachal Pradesh.
……..Complainant
Versus
1. New India Insurance Company Ltd. through its Branch Manager, SCO No.46-47, Phase-II, SAS Nagar, Mohali.
2. Raksha TPA through its Branch Head, SCO No.181, Second Floor, Sector 7-C, Chandigarh.
………. Opposite Parties
Complaint under Section 12 of the
Consumer Protection Act, 1986.
CORAM
Mrs. Madhu. P. Singh, President.
Shri Amrinder Singh Sidhu, Member
Mrs. R.K. Aulakh, Member.
Present: Shri N.S. Jagdeva, counsel for the complainant.
Shri Sukaam Gupta, counsel for the OPs.
(Mrs. Madhu P. Singh, President)
ORDER
The complainant has filed the present complaint seeking following direction to the Opposite Parties (for short ‘the OPs’) to:
- Set aside the repudiation letter dated 13.06.2014 and pay him medi-claim insurance of Rs.2,00,000/- alongwith interest @ 15%.
- To pay him Rs.1,00,000/- for harassment and mental agony.
- To pay him litigation cost to the tune of Rs.33,000/-.
The complainant took the Family Floater Mediclaim and Hospitalization Benefit Policy from OP No.1 by paying premium of Rs.6392/-. The policy was valid from 12th July, 2013 to 11th July, 2014 and the sum insured under the policy was Rs.2,00,000/-. Only the cover note of the policy was given to the complainant and no policy bond was received by the complainant from the OPs. The complainant was having very good health and did not suffer from any chronic disease nor has taken any treatment for such chronic disease. On 02.12.2013 the complainant suddenly suffered severe abdominal pain and Dr. Rajinder Kumar advised him to undergo Barium Meal Test which was conducted on 04.12.2013. It was found in the report that a large pocket has been formed near the large intestine containing fluids. Dr.Rajinder Kumar referred the complainant to GMCH, Sector 32 Hospital. The complainant visited GMCH, Sector 32 Hospital on 16.01.2014 and the doctors advised him to undergo surgery for removal of Divertukla developed near large intestine. Before surgery doctors also advised him to undergo Manometry Test to ascertain as if this disease can reoccur after surgery. This test was conducted on 19.02.2014 at PGI and the doctor of GMCH, Sector 32 Hospital after perusing the report asked the complainant to come for surgery on 24.02.2014. However, on the advice of family, the complainant decided to undergo surgery from Max Hospital, Mohali and accordingly the complainant visited Max Hospital on 27.02.2014 where the doctors conducted various tests and given 04.03.2014 the date for surgery. The insurance consultants of the hospital collected the details from the complainant about insurance and the hospital itself processed for cashless surgery. The Insurance Agency of the hospital informed the complainant that the cashless benefit has been refused by the OPs. The complainant was advised to get the surgery conducted and thereafter file a claim for reimbursement. Ultimately the surgery was successfully conducted on 04.03.2014 and the Max Hospital raised a bill of Rs.2,46,321/- which was made by the complainant. After discharge from hospital, the complainant lodged a claim of Rs.2.00 under the policy with OP No.1 on 25.03.2014. The documents sought by the OPs from the complainant on many occasions were supplied by him. However, the claim of the complainant was repudiated by the OPs on 13.06.2014 which was received by the complainant on 20.07.2014. The repudiation has been illegally done by the OPs under Clause 4.1 and 5.5 of the policy whereas the policy bond was never supplied to the complainant by the OPs. Thus, with these allegations the complainant has filed the present complaint.
2. The OPs in their joint written statement have pleaded that at the time of purchase of the policy each and every terms and conditions of the policy was explained to the complainant and after understanding the same, he agreed to purchase the same. The insurance policy was consisting of two pages and clauses were attached alongwith the same and were duly supplied to the complainant. The claim of the complainant was duly scrutinized and the complainant was asked to comply with certain claim formalities vide letter dated 03.04.2014 followed by reminders dated 18.04.2014, 03.05.2014 but the complainant never turned up for completion of formalities. From the medical record, OP No.2 found that the patient suffered from ‘Epihrenic Diverticulum; and record of the PGI Chandigarh showed symptoms of this disease for 6-7 months old. The disease is of chronic nature and take years to develop and hence was pre-existing to the policy inception. Thus, as per condition No.4.1 of the policy, the claim was outside the scope of the policy and was not payable. Intimation to this effect was given to the complainant on 13.06.2014. On merits, the OPs have denied any deficiency in service and unfair trade practice on their part and have sought dismissal of the complaint.
3. To succeed in the complaint, the complainant proved on record his affidavits Ex.CW-1/1 and Ex.CW-1/2 and copies of documents Ex.C-1 to C-11.
4. Evidence of the OPs consists of affidavit of Shri Sri Ram, their Sr. D.M. Ex.OP-1/1 and copies of documents Ex.OP-1 to OP-10.
5. We have heard learned counsel for the parties and gone through the written arguments filed by them.
6. The factum of Family Floater Mediclaim and Hospitalization Benefit Policy purchased by the complainant from OP No.1 and the validity of the said policy from 12th July, 2013 to 11th July, 2014 for a sum assured of Rs.2.00 lacs is not disputed.
7. The complainant developed some abdominal pain on 02.12.2013 and has undergone Barium Meal Test on 04.12.2013 as per advice of the doctor and upon investigation it was found that his large intestine has developed a large pocket where lot of fluid is accumulated. Upon doctor’s advice he has undergone surgery for removal of Divertukla developed near large intestine and remained indoor patient with PGI and GMCH Sector 32, Chandigarh from 19.02.2014 to 24.02.2014 for investigation and finally got the surgery done from Max Hospital, Mohali as indoor patient from 27.02.2014 to 04.03.2014. In this whole process of treatment he has spent a sum of Rs.2,46,321/- to Max Hospital, Mohali and after discharge preferred the medi claim for Rs.2.00 lacs under the policy with OP No.1 on 25.03.2014. The TPA i.e. OP No.2 has raised certain interim queries with the complainant vide Ex.OP-1 dated 03.04.2014 followed by reminder dated 18.04.2014 and 03.05.2014 i.e. Ex.OP-2 and Ex.OP-3. Since the complainant has not fulfilled necessary requisites and satisfied the queries of the OP No.1, then OP No.1 repudiated the claim of the complainant vide Ex.OP-4 on 13.06.2014 while invoking Clause 4.1 and 5.5 of the policy.
8. Whether the repudiation is legal and valid as terms and conditions of the policy or not is the issue involved in the present complaint? To answer this question it will be appropriate to go through clause 4.1 and 5.5 of the policy which reads as below:
“Clause 4.1
Pre-existing diseases/condition: 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 years provided there was no hospitalization for the pre-existing disease/ailment/ condition/injury during the said four years of insurance with our company.
Clause 5.5
Fraud, Misrepresentation, concealment: The policy shall be null and void and no benefits shall be payable in the event of misrepresentation, mis-description or non disclosure of any material fact/particulars if such claim be in any manner fraudulent or supported by any fraudulent means or device whether by the insured person or by any other person acting on his/her behalf.
9. It is admitted fact that the complainant has undergone surgery of Divertukla during his stay as indoor patient with Max Hospital, Mohali from 27.02.2014 to 04.03.2014. In order to establish that the complainant was suffering from pre-existing disease before purchase of policy and this fact was not revealed to the OPs upon inception of the policy, the OPs have relied upon Ex.OP-7 i.e. the pre- anesthesia record dated 16.01.2014 of Department of Anesthesia and Intensive Care, Govt. Medical College and Hospital, Sector 32, Chandigarh wherein as per hospital record the complainant was suffering from DLC from 15.03.2012.
10. In the written statement preliminary objections Para No.2, the OPs took a stand, that as per records of PGI the complainant was suffering from symptoms of ‘Epihrenic Diverticulum’ 6-7 months prior to commencement of the policy in July, 2013. However, this fact is not supported by any report from the PGI on record. On the other hand the discharge summary Ex.OP-8 of Max Hospital, Mohali makes some reference of PGI report showing no specific esophageal motility disorder and the said report is not disputed by the OPs.
11. Thus, the repudiation of the claim without any supportive evidence of pre-existing disease is not legal and valid as per clause 5.5 of terms of the policy. Clause 4.1 of the policy would have come into operation had the complainant was having knowledge of this disease prior to purchase of the policy and there is no document on record to show any pre-existing disease of ‘Epihrenic Diverticulum’ for which the complainant has undergone treatment and submitted his claim. The complainant cannot be denied the benefit of total sum assured of Rs.2.00 lacs against the actual treatment expenditure of Rs.2,46,321/-. Therefore, the answer of repudiation of the claim as per policy terms is against the OPs.
12. During the course of proceedings of the present complaint, the counsel for the OPs tried to show his concern on the ground that the documents have not been properly submitted before the TPA by the complainant. Therefore, at our instance the complainant has submitted fresh documents with the TPA i.e. OP No.2 was granted ample opportunities to make its stand clear before the Forum and OP No.2 has deliberately chosen not to resolve the issue. The conduct of the TPA, therefore, per se reveals its scant respect for policy holder as well as the legal process. From the above it is ample clear and evident that the OPs have repudiated the claim of the complainant not as per terms of policy and rather dishonoured the claim without any cogent and reliable evidence on record.
13. In view of above discussions, the complaint is allowed with the following directions to the OPs to:
(a) to entertain the claim of the complainant and pay him the due sum as per the policy against the submitted bills of Rs.2,46,321/-.
(b) to pay to the complainant a lump sum compensation of Rs.25,000/- (Rs. Twenty five thousand only) for mental agony, harassment and costs of litigation.
Compliance of the above directions be made within a period of thirty days from the date of receipt of a certified copy of this order. Certified copies of the order be furnished to the parties forthwith free of cost and thereafter the file be consigned to the record room.
Pronounced.
April 18, 2016.
(Mrs. Madhu P. Singh)
President
(Amrinder Singh Sidhu)
Member
(Mrs. R.K. Aulakh)
Member
