Haryana

Ambala

CC/177/2018

Pankul Singal - Complainant(s)

Versus

NIA - Opp.Party(s)

10 Jun 2019

ORDER

 

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AMBALA

 

                                                          Complaint case no.        :  177 of  2018

                                                          Date of Institution         :  04.06.2018

                                                          Date of decision    :   10.06.2019

 

Pankul Singal son of Sh. Mahesh Kumar, aged 22 years, resident of H.No. 315-A, Mahesh Nagar, Babyal Road, Ambala cantt.

 

  ……. Complainant.

 

 

The New India Assurance Company Ltd. 5406 2^nd Floor, Shree Complex, Cross Road No. 3, Punjabi Mohalla, Ambala Cantt. through its Manager.            

 

 ….…. Opposite Party.

 

Before:        Ms.  Neena Sandhu, President.

                   Ms. Ruby Sharma, Member.

                   Sh. Vinod Kumar Sharma, Member

 

 

Present:        Sh.Ajay Kumar Sahu, counsel for complainant.

 Sh. Nikhlesh Bhagi, counsel for OP

 

ORDER:     SH. VINOD KUMAR SHARMA, MEMBER.

                   Complainant has filed this complaint under section 12 of the Consumer Protection Act, 1986 (hereinafter referred to as ‘the Act’) against the Opposite Party (hereinafter referred to as ‘OP’) praying for issuance of following directions to the OP;

1. To pay Rs.1,55,000/- to the complainant alongwith interest @ 18% p.a. till the realization of actual payment.
2. To pay Rs.20,000/- as compensation for mental agony and physical harassment suffered by him.
3.  

Any other relief which this Hon’ble Forum may deem fit.

                    The brief facts of the present complaint is that the complainant had purchased the Medi claim policy, namely ‘New India Floater Medi Claim Policy’ bearing No. 353501342800000135 for himself, his father Sh. Mahesh Kumar Singhal and monther Smt. Parveen Singhal effective from 18.11.2014 to 17.11.2015, after paying premium of Rs. 20675/-.  During the subsistence of policy in question, the complainant ( one of the insured) suffered severe pain and blockage in his nose.  The complainant approached Dr. Anil Mittal, ENT, Abhenial Hospital, Ambala Cantt. and after examination the said doctor advised the complainant for nasal surgery.  In order to take second opinion the complainant approached Medanta Hospital, Gurgaon and remained there under treatment for 2 months, but the illness got worst.  Ultimately, the complainant finally approached/contacted Apollo Hospital, New Delhi.  After examination by the doctor nasal surgery advised. Keeping in view the  seriousness of the disease, the complainant agreed for surgery and submitted insurance papers of the expenses covered under the policy in question for insurance claim.  The Apollo Hospital informed the complainant that company had denied the compensation/claim for nasal surgery under the policy in question.  Even then the complainant had under gone nasal surgery and had borne the expenses out of his own pocket.  After surgery the complainant contacted the OP.,but the OP. told the complainant No claim can be given for nasal surgery and the same can be allowed only after two years of the taking of policy.  It is not out of place to mention that  at the time of purchase of the policy the agent had assured the complainant, his father and mother that the policy will provide 100% reimbursement on every medical expenses, incurred by the complainant etc. for his physical treatment or that of  his father and mother, upto the limit of Rs. 8.00 lacs and had not told any such arbitrary condition for taking any claim/ reimbursement of nasal surgery.   There is no mention of any such limitation on the policy purchased by the complainant and no intimation of any such limitation is ever given to the complainant  by the OP.  At the time of selling the policy neither the agent of OP. told about the limitation to the complainant nor the complainant, his father and mother had entered into any such agreement with the OP. qua such limitation.  Further the complainant had incurred an expenditure of Rs. 1,55,000/- on the nasal surgery from Apollo Hospital, New Delhi and the bill for the same already submitted to the OP. and also a notice was served to the OP. through Advocate.  The complainant had also filed a complaint against the OP before this Forum.  The said complaint was disposed off by this Forum vide order dated 8.2.2018 after recording the statement of complainant to the effect that the OP. will decide the claim of the complainant within 45 days after receiving the claim documents.  After that the complainant had filed the claim in the office of OP and OP. informed the complainant vide letter dated 21.2.2018 to submit the claim documents in the office of Raksha TPA at SCO No. 359-360, Sector 44-D, Chandigarh and assured the complainant to release the same.  On dated 19.4.2018, the Regional office of the OP. refused the claim of complainant.    Hence, the present complaint.    

2.                Upon notice, OP appeared through counsel and tendered written statement  and stated that at the time of purchasing New India Floater Medi claim policy on 18.11.2014 all the terms and conditions were informed/communicated to the complainant including list of  diseases with specification of its coverage.  The complainant had submitted a claim for nasal surgery through Apollo Hospital and above said disease fall under clause 4.3.1 and as per clause 4.3.1. all diseases falling under it have to be excluded from the scope of the policy for 24 months.  The Insurance company rightly repudiate the claim  as it does not cover the disease mentioned under 4.3.  The complainant was never assured by the agent of OP. that the policy will provide 100% reimbursement on every medical expenses as alleged.  The complainant had accepted the policy after agreeing all the terms and conditions including  the details of disease like nose( Nasal Surgery) not coverable for two years from the date of policy.  The complainant already had knowledge about the terms and conditions of the policy and he purchased the policy after admitting its terms and conditions.  Further, the OP. had never misrepresented the complainant that all expenses upto Rs. 8.00 lac will be paid in case of any disease.  The diseases and its covering period has already been communicated to the complainant.   So, the complaint of the complainant is false, devoid of merits and prayed for dismissal of the present complaint.

3.                To prove his version complainant tendered his affidavit as Annexure CA along with documents as annexure C-1 to C-9 and close his evidence. On the other hand, Counsel for the OP tendered affidavit as Annexure OP-A alongwith documents as Annexure OP-1 to OP-9 and closed the evidence.  

4.                We have heard both the counsels of the parties and carefully gone through the case file.

5.                The learned counsel for the complainant has argued that the complainant was not satisfied with the terms and condition of the policy in question as the same were not communicated /intimated to him at the time of selling the policy in question. The agent of the OP had assured the complainant, his father and mother that during the policy period, the policy will provide 100% reimbursement on every medical expenses incurred by the complainant etc. for his physical treatment or that of father and mother upto the limit of Rs.8.00 lacs and had not told any such arbitrary condition for taking any claim/reimbursement of nasal surgery as such complainant requested the Ops to pay Rs.1,55,000/- incurred by him on his nasal surgery, the OP refused to pay the said amount vide letter dated 7.5.2018 (Annexure-C5). This act of Ops amounts to deficiency in service.

                   The learned counsel for the OP has argued that at the time of purchase of the policy in question all terms and conditions were informed/communicated to the complainant including list of diseases with specification of its coverage. As per list some disease fall under clause 4.3 and are coverable after 24 months. It has been further argued that complainant had submitted claim for nasal surgery through Apollo Hospital and the above said disease fall under clause 4.3.1 and as per clause 4.3.1 all diseases falling under it have to be excluded from the scope of the policy for 24 months. The OP has rightly repudiate the claim of the complainant as it does not cover the diseases mentioned under 4.3.1.  The complainant has claimed the above said amount of treatment as per policy but OP repudiated the claim as per Section 4.3.1 exclusion clause. The counsel for the OP. has also relied upon the following case laws:

1. National Insurance Company Ltd. Vs. Abdul Razad (2016)(1) CPJ 649
2. National Insurance Co. Ltd. Vs. Arun Kumar Goyal (2011) (1) CPJ 266
3. Nimai Chandra Bhattacharjee Vs.  National Insurance Co. Ltd. (2012) (3) CPJ 265
4. Reena Kansal Vs. United India Insurance Co. & Anr. (2015)(1) CPJ 523

6.                We have gone through the above said clause, clause 4.3.1 of the policy terms, nasal surgery is excluded for initial two years of Medi claim policy (Annexure-OP/9) which thus falls under exclusion  clause and expenses incurred on the treatment are not payable. In the present case, the complainant has obtained the medical policy for one year i.e. 18.11.2014 to 17.11.2015 and the complainant has taken the  treatment from the Apollo Hospital, New Delhi and nasal surgery has been got done within two years. In this way, the complainant has not completed of two years continue policy as per terms and conditions of the policy. So in view of the above facts, it is clear that the complainant is not entitled the medical claim. Therefore, the case of the complainant covered under the exclusion sub clause 4.3.1 of the policy. We do not find any deficiency in service on the part of Ops. Thus, the complainant is not entitled any relief. Hence, the present complaint is liable to be dismissed and same is hereby dismissed with no order as to cost. Copy of this order be supplied to both the parties free of cost. File be consigned to record room after due compliance.

Announced on : 10.06.2019

 

 

 

 (Vinod Kumar Sharma)       (Ruby Sharma)                          (Neena Sandhu)

      Member                             Member                            President