BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SIRSA.
Consumer Complaint no. 368 of 2019
Date of Institution : 11.07.2019
Date of Decision : 25.02.2021
Sudhir Kumar (aged about 57 years) son of Sh. Bansi Lal, resident of Gali Jain School, Bhadra Bazar, Opposite Shanker Chiterkaar, Sirsa-125055, District Sirsa (Haryana).
……Complainant.
Versus.
- National Insurance Company Limited, through its Divisional Manager, Divisional Office, Near Sangwan Chowk, SIRSA- 125055 (Haryana).
- MedSave Health Insurance TPA Limited, through its Authorised Signatory, SCO-66, Second Floor, Sector 10-C, Chandigarh.
...…Opposite parties.
Complaint under Section 12 of the Consumer Protection Act,1986.
Before: SH. RAGHBIR SINGH………………. ……PRESIDENT.
MRS. SUKHDEEP KAUR……………..MEMBER.
Present: Sh. Anil Bansal, Advocate for the complainant.
Sh. A.S. Kalra, Advocate for opposite party No.1.
Opposite party no.2 exparte.
ORDER
The case of the complainant, in brief, is that the complainant has been purchasing Medi claim insurance policies from opposite party no.1 regularly since 2013-14 and recently complainant purchased a medi claim insurance policy for his family i.e. for himself and his wife namely Smt. Saroj Devi from op no.1 through op no.2 vide policy No.420700501710000033 for sum assured of Rs.2,00,000/-, which was effective from 10.1.2018 to 9.1.2019. He paid insurance premium of Rs.9318/- in this regard and policy was further renewed for one year vide policy No.420700501810000138 w.e.f. 10.1.2019 to 9.1.2020 by paying further insurance premium of Rs.9318/-. It is further averred that at the time of taking above policies, op no.1 assured him that in the event of any health problem to any of the family members occurring within the period of insurance covers, the expenses for such health problems/ treatment would be borne by ops and claim of such expenses would be reimbursed to the insurer at the earliest. It is further averred that during the period of above policies, complainant Sudhir Kumar got treatment of GAMMA KNIFE THERAPY from All India Institute of Medical Sciences, New Delhi and incurred Rs.78,150/- (which includes operation fees and different medical tests etc.) in December, 2018 and January, 2019. He remained under treatment w.e.f. 21.12.2018 to 11.1.2019 and above said operation was carried out by concerned doctors of AIIMS, New Delhi on 11.1.2019. That soon after the operation, the intimation of treatment was given to op no.1 on 19.1.2019 alongwith claim form of Rs.78,150/- and he submitted all required bills and treatment papers and op no.1 further assured that claim would be got settled through op no.2 for making payment to him and shall be informed very soon. It is further averred that instead of settling claim of complainant, ops are postponing the matter with one pretext or the other. The complainant visited the office of op no.1 time and again and repeatedly contacted op no.2 as well on telephone, but no satisfactory reply was ever given. That ultimately complainant got served legal notice to the ops on 23.5.2019 for settling his claim and also requested to intimate regarding exact status of claim of complainant. It is further averred that in response to legal notice, a reply dated 2.7.2019 of op no.1 was received and complainant was astonished to know from contents of reply that insurance claim of complainant has been repudiated on the ground that “The claim is not admissible as it does not fall within the scope of cover of the policy.” That previously complainant never received such information of repudiation of claim from any of the ops and in the reply to notice dated 2.7.2019, no date of repudiation letter has been mentioned. Moreover, no copy of repudiation letter has been provided/ sent to him till date and no details of repudiation of claim has been provided to him. The complainant came to know about repudiation of his claim on 2.7.2019. It is further averred that no terms and conditions of exclusion clauses were ever supplied/ sent to complainant at the time of doing insurance or thereafter during the period of insurance i.e. 10.1.2018 to 9.1.2020. That ops are guilty of deficiency of service as well as gross negligent in discharging their duties. The conduct of ops clearly shows that they are indulged in unfair trade practice. The complainant is legally entitled to get amount of his insurance claim of Rs.78,150/- alongwith an amount of Rs.50,000/- as compensation and Rs.12,000/- as legal expenses. Hence, this complaint.
2. On notice, opposite party no.1 appeared and filed written statement raising certain preliminary objections that complaint is not maintainable in the present form; that there is no deficiency in service in any manner on the part of company or its officials, as claim has been decided by op no.2 an authority vested with the powers to deal with the claim related to third party, without having any interest in either party (insured or insurer), hence allegations leveled against answering op are baseless and complaint is liable to be dismissed; that claim lodged by complainant is not tenable, hence has been repudiated by TPA/ op no.2 in exercising the powers vested with it according to the term and conditions of the policy, as the disease for which the claim lodged by complainant does not fall within the purview of term and conditions of insurance policy, hence complaint is without any cause of action and that complaint is false and frivolous and same is liable to be dismissed with special costs. On merits, it is submitted that treatment and payment of any claim is subject to term and conditions of the policy. Treatment and expenses is also matter of record and is not disputed, but the treatment charges incurred are not payable, hence were not paid being not admissible as Gamma Knife Therapy is not covered under the policy and the claim lodged by complainant was not admissible, as it was not falling within the scope of coverage of policy. It is further submitted that claim is to be decided by the TPA having team of experts with them and TPA has been given right and authority to decide the claim lodged by any individual according to the IRDA regulation/ Central Govt. policy. While denying the remaining contents of the complaint being wrong and incorrect, it is submitted that after receipt of claim form, the matter was enquired and Competent Authority has decided the claim lodged by complainant by passing an order dated 12.2.2019 and intimation in this regard has been sent to complainant by op no.1. It is further submitted that complainant is an educated person and a lame excuse has been taken by him about not going through the term and conditions of policy or exclusion clauses. No one can take plea that he does not know the term and conditions of the policy, exclusion clauses, when he taking policies having specific reference therein about website, product, service and grievance redressal. All other contents of the complaint are also denied and prayer for dismissal of complaint made.
3. Opposite party no.2 did not appear despite issuance of notice through registered cover and as such opposite party no.2 was proceeded against exparte.
4. The parties then led their respective evidence.
5. Learned counsel for complainant has tendered in evidence affidavit of complainant Ex.CW1/A, copy of policy schedule Ex.C1, copy of policy Ex.C2, copy of prescription slip Ex.C3, copy of bill Ex.C4, copies of cash receipts Ex.C5, Ex.C6, copy of diagnostic report Ex.C7, copy of cash memo Ex.C8, copy of MRI report Ex.C9, copy of receipt Ex.C10, copy of claim form Ex.C11, copy of claim process sheet Ex.C12, copy of legal notice Ex.C13, copies of postal receipts Ex.C14, Ex.C15 and copy of reply to legal notice Ex.C16. On the other hand, learned counsel for op no.1 has tendered affidavit of Sh. V.K. Gumber, Divisional Manager as Ex.R1, copy of repudiation letter Ex.R2, copy of medical record Ex.R3, copy of prescription slip Ex.R4, copy of clinical MRI requisition form Ex.R5, copy of MRI report Ex.R6, copy of policy Ex.R7, copy of policy schedule Ex.R8 and copy of terms and conditions Ex.R9.
6. We have heard learned counsel for the parties and have gone through the case file carefully.
7. Admittedly the complainant had purchased a medi claim insurance policy for himself and his wife namely Smt. Saroj Devi from opposite party no.1 through op no.2 vide policy No.420700501710000033 for sum assured of Rs.2,00,000/- for the period 10.1.2018 to 9.1.2019 and he paid premium of Rs.9318/- in this regard. This fact is proved from the copy of policy schedule Ex.C2. This policy was further got renewed by the complainant for the period 10.1.2019 to 9.1.2020 vide policy No.420700501810000138 by paying premium amount of Rs.9318/- as is evident from copy of policy schedule Ex.C1.
8. According to the complainant during the subsistence of the policies in question, he got treatment of Gamma Knife Therapy from All India Institute of Medical Sciences, New Delhi and incurred Rs.78,150/- on his above said treatment and he remained under treatment in AIIMS, New Delhi from 21.12.2018 to 11.1.2019. Said fact of his admission in the said hospital and treatment is also proved from prescription slip dated 21.12.2018 Ex.C3. The complainant has also placed on record copies of bill and receipts (Ex.C4 to Ex.C6, Ex.C8 and Ex.C10) of the amount of Rs.78,150/- spent on his above said treatment. The claim of the complainant has been rejected by the opposite parties on the ground that claim is not admissible as it does not fall within the scope of cover of the policy. According to op no.1, claim lodged by complainant has been repudiated by the op no.2/TPA exercising the powers vested with it according to the term and conditions of the policy as the disease for which the claim lodged by complainant does not fall within the purview of term and conditions of insurance policy. Admittedly, the complainant got treatment of “GAMMA KNIFE THERAPY” which therapy is used to treat tumors etc. in the brain area and the said treatment is not excluded in the terms and conditions of the insurance policy placed on file by op no.1 as Ex.R9. Moreover, according to learned counsel for complainant, even ops did not communicate the terms and conditions of the insurance policy to the complainant and he has also relied upon judgment of the Hon’ble Supreme Court in case titled as Bharat Watch Company Through its Partner Vs. National Insurance Co. Ltd. through its Regional Manager CA Nos.3912 of 2019 decided on 12.4.2019. We also agree with the contention of learned counsel for complainant as ops have failed to prove on record that terms and conditions of the policy were sent to the complainant alongwith policy schedule. The Hon’ble Supreme Court of India in case of Bharat Watch Company Vs. National Insurance Co. Ltd. (Supra) has held as under:-
“Consumer Protection Act, 1986 Section 23 Claim of insurance- Non-communication of condition- Theft committed in shop of claimant by using duplicate keys- There was no sign of forcible entry- Where loss or damage was caused without forcible and violent entry to premises claim could not be maintained- This exclusionary condition in policy not communicated to claimant- Claim was allowed by District Forum and upheld by State Commission on said concurrent finding- NCDRC erred in reversing decision of District Forum and State Commission- Order set aside.”
9. The above said authority is fully applicable to the facts and circumstances of the present case. Firstly, the disease for which the complainant was treated is not mentioned in the exclusion clauses of the policy where names of pre-existing, excluded diseases and waiting period of diseases are mentioned and secondly the opposite parties have not provided terms and conditions of the insurance policy to the complainant. Op no.1 has also placed on record printed medical record dated 11.1.2019 Ex.R3 allegedly issued by AIIMS New Delhi to show that complainant was having pain in right half of face for the past two years exaggerated by chewing/ talking and according to learned counsel for op no.1 the complainant suppressed the material fact of his ill-health at the time of taking the insurance policy, so he is not entitled to any claim on the ground of misrepresentation of material facts. But however we find no substance in the contention of learned counsel for op no.1 as Ex.R3 is simple printed paper and it does not bears any signatures of the issuing authority. The op no.1 has not filed any affidavit of the doctor/ authority from whom the ops brought the said printed document and op no.1 has also not filed any affidavit of the doctor who had mentioned the medical history, so this document has no evidentiary value. The opposite party no.2 has failed to appear and to contest the present complaint rather opted to proceed against exparte. So, we are of the considered view that opposite parties have wrongly and arbitrarily repudiated the genuine claim of the complainant. The complainant has proved on record that he has spent an amount of Rs.78,150/- on his above said treatment and non reimbursement of the said amount clearly amounts to deficiency in service and unfair trade practice on the part of the opposite parties.
10. In view of our above discussion, we allow this complaint and the repudiation of the claim of the complainant is hereby set aside. We direct the opposite parties to pay the claim amount of Rs.78,150/- to the complainant alongwith interest @6% per annum from the date of filing of present complaint till actual realization within a period of 30 days from the date of receipt of copy of this order, failing which the complainant will be entitled to interest @9% per annum on the above said amount from the date of filing of present complaint till actual realization. We also direct the opposite parties to pay a sum of Rs.5,000/- as compensation for harassment and Rs.2000/- as litigation expenses to the complainant within above said period of 30 days. A copy of this order be supplied to the parties free of costs. File be consigned to the record room.
Announced in open Forum. Member President,
Dated:25.02.2021. District Consumer Disputes
Redressal Commission, Sirsa.
