Punjab

Sangrur

CC/356/2014

Harbans Singh - Complainant(s)

Versus

NIC Ltd. - Opp.Party(s)

Shri S.M. Goyal

13 Mar 2015

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.

 

                                                               

                                                Complaint No.    356

                                                Instituted on:      01.07.2014

                                                Decided on:       13.03.2015

 

1.Harbans Singh aged about 48 years son of Joginder Singh.

2.Kulwant Kaur aged about 46 years wife of Harbans Singh, both residents of Village Balewal, Post Office Bhogiwal, Tehsil Malerkotla, Distt. Sangrur.

                                                        …Complainants

                                Versus

1.     National Insurance Company Limited through its Branch Manager, Thandi Sarak, The Mall, Malerkotla.

2.     Vipul Medicorp TPA Pvt. Ltd. through its Branch Manager, SCI 98, FF, Industrial Area, Phase II, Chandigarh.

                                                                ..Opposite parties

 

 

For the complainants   :       Shri S.M.Goyal, Advocate.

For Opposite party No.1:    Shri Anil Aggarwal, Advocate.

For Opposite party No.2:    Exparte.

 

 

Quorum:    Sukhpal Singh Gill, President

                K.C.Sharma, Member

                Sarita Garg, Member

 

 

Order by : K.C.Sharma, Member.                                     

                                               

 

1.             Shri Harbans Singh and Smt. Kulwant Kaur,  complainants (referred to as complainants in short) have preferred the present complaint against the opposite parties (referred to as OPs in short) on the ground that the complainant number 1 got hospitalization benefit policy from OP number 1 vide which the complainant number 1 and his wife complainant number 2 were insured under policy number 404202/48/11/8500000137, which was issued by the OP in favour of the complainants for the period from 3.8.2011 to 2.8.2012 against the requisite premium of Rs.11,419/-. It is further averred that no terms and conditions of the policy were ever supplied to them. It has been further averred that the complainants also got insured themselves under policy number 404202/48/10/8500000285 for the period from 3.8.2010 to 2.8.2011. Again the complainants got insured themselves from the OPs under policy number 404202/48/12/85000000200 for the period from 3.8.2012 to 2.8.2013 and thereafter for the period from 6.8.2013 to 5.8.2014 under policy number 404/202/48/11/8500000142.

 

2.             It is averred in the complaint that in the month of October, 2011, the complainant number 2 felt severe pain in her joints, fever and tiredness just doing a little house hold work due to which she felt pain in whole of her body, as such she approached Dayanand Medical College and Hospital, Ludhiana on 15.11.2011 for check up, where some tests were performed on her and was advised to come back after 20/22 days.  It is further averred that the complainant number 2 approached again Dayanand Medical College and Hospital, Ludhiana on 9.12.2011, where she was admitted on 9.12.2011 and was discharged on 10.12.2011 after examination and the complainant number 2 was disclosed a case of Hepatitis-C and Smt. Kulwant Kaur was advised complete bed rest and prescribed the medicines.   Thereafter, the complainants submitted the claim along with the documents to OP number 1 to pay the claim amount. Thereafter the complainants also submitted to OP number 1 a certificate issued by Dr. Sandeep Chhabra in which it is clearly mentioned that Hepatitis-C could not be ascertained as it could be an accidental needle stick injury case.  It is further stated that the complainants received a letter dated 5.7.2012 from OP number 2 whereby stating that the complainant did not intimate the insurance company within 7 days as she was suffering from Hepatitis-C since long.   As such, alleging deficiency in service on the part of the OPs, the complainant has prayed that the OPs be directed to pay to the complainants an amount of Rs.4,25,000/- along with interest @ 24% per annum and further to pay compensation and litigation expenses.

 

3.             In reply filed by OP number 1, legal objections are taken up on the grounds that the claim is not payable as per the terms and conditions of the policy, as the disease was pre- existing one and that the complaint is wrong and false.  On merits, it is admitted that the complainants got a medi claim policy form OP number 1 for the period from 3.8.2011 to 2.8.2012.  It has been admitted that the claim was lodged by the complainants with OP number 1 on account of medical treatment of complainant number 2, Smt. Kulwant Kaur for acute viral Hepatitis-C. It is further admitted that the OP number 1 sent the claim to OP number 2 for necessary action.  It is further stated in the reply that the complainant lodged the complaint very late, whereas it was required to be submitted within 7 days, but despite issuing of the said letter, the complainant did not submit any reply as per discharge summary submitted to the company. It is further stated that the complainant intimated the DMC that it was a case of HCV positive since four years and she is covered under mediclaim policy since 3.8.2008, hence the disease is pre existing one and the claim is not admissible under clause 4.1.  It has been further stated that the complainant has even failed to reply the letters dated 21.3.2012 and 7.5.2012 sent to the complainant requesting to intimate from how long she is suffering from the said disease.  Any deficiency in service on the part of the OP has been denied.

 

4.             Record shows that OP number 2 did not appear despite service and was proceeded exparte on 29.12.2014.

 

5.             The learned counsel for the complainant has produced Ex.C-1 to Ex.C-4 copies of insurance policy, Ex.C-5 copy of letter, Ex.C-6 to Ex.C-7 ID cards, Ex.C-8 copy of letter dated 7.5.2012, Ex.C-9 copy of medical certificate, Ex.C-10 to Ex.C-11 copy of prescription slip, Ex.C-12 copy of certificate issued by DMC, Ex.C-13 to Ex.C-48 copies of medical bills, Ex.C-49 to Ex.C-56 copies of Lab reports, Ex.C-57 and Ex.C-58 are affidavits and closed evidence. On the other hand the learned counsel for OP number 1 has produced Ex.OP1/1 copy of insurance policy, Ex.OP1/2 copy of terms and conditions, Ex.OP1/3 copy of proposal form, Ex.OP1/4 affidavit and closed evidence.

6              We have carefully perused the complaint, written version of the opposite parties, evidence of the parties and heard the arguments of the learned counsel for the parties. In our opinion, the complaint merits part acceptance, for these reasons.

 

7.             It is not in dispute between the parties that the complainants are insured with the Ops under policy number 404202/48/11/8500000137 for the period from 3.8.2011 to 2.8.2012 by paying the requisite premium of Rs.11,419/- to the OPs, vide policy Ex.C-2. It is also admitted fact that the claim arose within the subsistence of the insurance policy in question.

 

8.             The version of the complainant is that the OPs have not settled the claim stating that the insured/complainant was having a pre-existing disease at the time of obtaining the insurance policy in question and had also raised certain queries vide document Ex.C-8. The complainant had submitted the copy of certificate issued by the Dayanand Medical College and Hospital, Ex.C-12 to the OP number 1, in which it is mentioned that the cause of Hepatitus-C could not have been ascertained as it could be an accidental needle stick injury.  But, the Ops have not still settled the rightful claim of the complainants.

 

9.             On the other hand, the learned counsel for the OP number 1 has vehemently contended that since the complainant number 2, Kulwant Kaur was having pre-existing disease of Hepatitus-C, as such, she is not entitled to get any claim from the OPs.

 

10.            After hearing the arguments of the learned counsel for the parties and on the perusal of the documents placed on record, we find that the main point of controversy in this complaint is whether the complainant number 2 was having a pre-existing disease of Hepatitus-C prior to obtaining the insurance policy or not.  

 

11.            The learned counsel for OP number 1 has pointed out that as per the document Ex.C-10 in the history and examination, it has been mentioned that ‘R/C/O-HCV + x 4 years’, which shows that at the time of admission of the complainant number 2 in the Dayanand Medical College and Hospital on 10.02.2011, she was having HCV + for the last four years as per the document Ex.C-10 and as such, the claim of the complainant is not admissible as the complainant number 2 was having a pre existing disease before issuance of the policy in question.  In order to prove such a fact, the OP number 1 has not led any other evidence with regard to the disease and treatment thereof taken by her for the period so alleged by OP number 1 and in the absence of any conclusive evidence only the mention of disease for the last four years cannot be relied upon and that too when the doctor of the same hospital vide document Ex.C-9 in the column 7, it has also been mentioned that the disease is for the last four months.  As such, we are unable to accept the contention of the learned counsel for OP number 1 that the complainant number 2, Smt. Kulwant Kaur was suffering from the disease for the last four years.

 

12.            Now, coming to the quantum of compensation payable by OP number 1 to the complainant. In the present case, the OP number 1 has not settled the amount payable to the complainant on account of treatment of complainant number 2 Smt. Kulwant Kaur till now.  Further there is no explanation from the side of the complainant that how she has claimed such a huge amount of Rs.4,25,000/-, whereas the insurance policy in question is only for Rs.2,50,000/-, which is on record as Ex.C-2.  As such, we feel that the ends of justice would be met if the Ops are directed to settle the claim of the complainants on the basis of the documents submitted by her with the OP number 1.

 

13.            In view of our above discussion, we allow the complaint partly and direct the OP number 1 to settle the claim of the complainants on the basis of the documents submitted by her with the OP number 1 and intimate the complainants accordingly.  We further order the Op number 1 to pay to the complainants an amount of Rs.15,000/- on account of compensation for mental tension, agony and harassment and Rs.5000/- on account of litigation expenses. 

 

14.            This order of ours be complied with within a  period of 45 days of receipt of this order.  A copy of this order be issued to the parties free of cost. File be consigned to records.

                Pronounced.

                March 13, 2015.

 

 

                                                        (Sukhpal Singh Gill)

                                                           President

 

 

                                                              (K.C.Sharma)

                                                                Member

 

 

                                                                (Sarita Garg)

                                                                   Member