BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SIRSA.
Consumer Complaint no. 168 of 2016
Date of Institution : 15.7.2016
Date of Decision : 9.5.2017.
Mamta Gupta aged 40 years w/o Atul Gupta, resident of C/o Gupta Paints, Subhash Chowk, Sirsa, Tehsil and District Sirsa.
….Complainant.
Versus
1. National Insurance Company Limited, 1st Floor, Old L.I.C. Building, Near Sangwan Chowk, Sirsa through its Divisional Manager/ Authorized person.
2. National Insurance Company Limited, Regd. Office at 3 Midelton Street, Post Box No.9229, Kolkatta 700 071 (WB)
3. Vipul Med Corp. TPA Pvt. Ltd., 515 Udyog Vihar, Phase V, Gurgaon, Haryana.
..…Opposite parties.
Complaint under Section 12 of the Consumer Protection Act,1986.
Before: SH. RAGHBIR SINGH…………………PRESIDENT
SMT. RAJNI GOYAT ……….……MEMBER.
SH. MOHINDER PAUL RATHEE…………MEMBER
Present: Sh. N.K. Daroliya, Advocate for the complainant.
Sh. Ravinder Goyal, Advocate for opposite parties.
ORDER
Case of complainant, in brief, is that husband of complainant being the eligible person purchased the insurance policy covering the medical risk to his life as well as his family members consisting the complainant and sons Raghav and Shivam. The husband of complainant purchased policy from ops namely “Parivar Mediclaim” bearing No.420700/48/15/8500000107 date of commencement 14.5.2015 to 13.5.2016 against the premium amount of Rs.10693/-and mode of payment was yearly. At that time all the requisite forms were duly got filled up by the husband of complainant through their agent bearing code No. (209) & contact No.9812177416 and through enquiry was got done by the ops qua the health of the insured through their Dr. V.P.Goyal, Holy Nursing Home, Sirsa and as the insured were found as medically fit persons, the ops supplied the insurance policy. It is further averred that Sh. Atul Gupta husband of complainant was/is regular customer of the insurance company and for the betterment of himself as well as for his family purchased first medi-claim policy in the year 2010 which was effective from 14.5.2010 and thereafter he had purchased next policy from the New India Assurance Company Ltd., Sirsa dated 13.5.2011 which was effective from 14.5.2011 to 13.5.2012 and premium of Rs.5670/- was paid and the insured amount was Rs.4,00,000/- for the insured persons. The said policy was followed by next policy from the same company vide policy No.35370034120100000012 dated 14.5.2012 valid from 14.5.2012 to 13.5.2013. Thereafter husband of complainant ported the insured policy in the other company namely National Insurance Co. Ltd. Sirsa and purchased the above said policy (hospitalization benefit policy) for a sum of Rs.5,00,000/- valid from 14.5.2013 to 13.5.2014 and paid a premium of Rs.9517/- on 9.5.2013 and this policy was duly ported in the National Insurance Company Ltd. from New India Insurance Co. Ltd. and it was assured by the ops that last two years during which the husband of complainant purchased the mediclaim policy will be treated and counted in the waiting period for the policy issued by their office and it will be deemed to be continue policy from the date 14.5.2010 and also assured that complainant is entitled for all the benefits under their policy being treated as continue from year 2010 as mentioned above. It is further averred that since the complainant is policy holder/ insured w.e.f. 2010, she kept the policy continue till date, as such the above mentioned policy dated 14.5.2013 was followed by the next policy dated 14.5.2010 and further continued vide policy dated 14.5.2015 which is valid w.e.f. 14.5.2015 to 13.5.2016 and deposited premium amount in time. However, due to bad luck of complainant on 15.2.2016 she suffered hypothyroidism, presented with complaints of progressive breathlessness for 6-7 days, bilateral pedal odema & dyspnoea on minimum exertion for 3-4 days, she was investigated outside and detected to have ventricular bigeminy. She was admitted for further treatment and after that undergone medical check from doctors of Sir Ganga Ram Hospital, Delhi and as per diagnose by the doctor got conducted various tests and accordingly the complainant undergone treatment from the said Hospital where she remained admitted from 15.2.2016 to 17.2.2016. The complainant immediately informed and applied for hospitalization claim amount of medical treatment and submitted the medical bills of Rs.70,383/- and according to the sum assured under Medical Policy, the complainant is legally entitled for the amount of Rs.70,383/- being the medical bills alongwith other expenses for medicine and drugs, diagnostic procedure, diet charges, nursing care etc. However, the ops issued a letter dated 5.5.2016 and demanded some paper formalities from the complainant which were also completed. It is further averred that thereafter the ops acting in a gross unfair manner and acting in a monopolistic way repudiated the claim of complainant on false pretext and thereafter put off the matter on one pretext or the other. Hence, this complaint.
2. On notice, opposite parties appeared and filed written statement taking certain preliminary objections regarding maintainability; locus standi; suppression of material facts and estoppal etc. It has also been submitted that the claim of complainant has been repudiated by the ops in a legal and lawful manner on the ground that “as per investigation report submitted, patient is diagnosed to have DN-II, Upper respiratory tract obstructions with hypothyroidism and patient is K/C/O DM-II since 6 years and as per records available, insured is covered since 14.3.2013 (running 3rd year). As disease is pre-existing, hence claim is not admissible under clause 4.1/Parivar Mediclaim.” So, there was/is no deficiency in service on the part of the ops in rendering the claim of complainant as No claim and no consumer dispute is made out between the parties. On merits, the pleas taken in the preliminary objections have been reiterated, contents of complaint have been denied and prayer for dismissal of complaint has been made.
3. In evidence, complainant produced her affidavit Ex.C1, affidavit of Sh. Atul Gupta Ex.C2, copy of mediclaim policy Ex.C3, copy of claim form Ex.C4, copy of report Ex.C5, copy of discharge summary Ex.C6, copy of letter Ex.C7, copy of prescription slip dated 15.2.2016 Ex.C8, copies of medical records, copies of policies and bills Ex.C9 to Ex.C25. On the other hand, ops produced copies of documents Ex.R1 to Ex.R8.
4. We have heard learned counsel for the parties and have perused the case file carefully.
5. There is no dispute that husband of complainant is having mediclaim policy since 14th May, 2010 which was issued by New India Assurance Company Ltd. and was for Atul Gupta i.e. husband of complainant as well as for complainant and their two sons namely Raghav and Shivam as is evident from copy of policy schedule Ex.C19 and has been got continuously renewed from New India Assurance Company Ltd. up to the month of May, 2013. Then the husband of the complainant is obtaining the medi-claim insurance policy from the National Insurance Company Ltd. since 14.5.2013 and is renewing the policy in question up to date by paying requisite annual premium of Rs.9517/-. According to the complainant the medi claim insurance policy obtained by husband of the complainant from New India Assurance Company Ltd. for himself as well as his family members since year 2010 has been ported with National Insurance Company Ltd. since 14.5.2013 and at that time it was assured by the ops that last two years during which the husband of complainant purchased the medi-claim policy from the New India Insurance Co. Ltd. Sirsa will be treated and counted in the waiting period for the policy issued by their office and it will be deemed to be a continue policy from the date 14.5.2010 and also assured that the complainant is entitled for all the benefits under the policy being treated as continue from year 2010. It has come on record that the husband of the complainant is continuing the medi-claim policy for himself and her family members including the complainant from the year 2010 by requisite premiums and continuing the policy in question with ops since 2013. As such the repudiation of the claim of the complainant for the amount of Rs.70,383/- being the medical bills and other expenses for medicine, diet charges and nursing care etc. on the basis of above said exclusion clause 4.1 is not correct and not justified because the ops continued the medi-claim of the policy earlier purchased from the New India Insurance Co Ltd. in the year 2010. Therefore, the said exclusion clause will not apply to the case of the complainant. Moreover, there is nothing on record to prove that complainant is having pre-existing disease for the last six years as alleged by the ops. No previous medical/ treatment record from any hospital in this regard of the complainant has been placed on file by the ops. There is nothing on record to prove that complainant was diagnosed to have DM-II, upper respiratory tract obstruction with hypothyroidism and is K/C/O DM-II since 6 years except the endorsement of the investigator. In these circumstances, the repudiation of the claim of the complainant for the amount of Rs.70,383/- is not justified and is set aside and complainant is entitled for the said amount from the ops.
6. Keeping in view the facts and circumstances of the present case, we allow the present complaint and direct the opposite parties to reimburse the amount of Rs.70,383/- to the complainant within a period of one month from the date of receipt of copy of this order, failing which the complainant will be entitled to interest @9% per annum from the date of order till actual realization. This order should be complied by all the ops jointly and severally. A copy of this order be supplied to the parties free of costs. File be consigned to record room after due compliance
Announced in open Forum. President,
Dated: 09.05.2017. District Consumer Disputes
Redressal Forum, Sirsa.
Member Member.
