DISTRICT CONSUMER DISPUTES REDRESSAL FORUM

(CENTRAL) ISBT KASHMERE GATE DELHI

CC No. 86/2016

No. DF/ Central/                                                                      Date

Sandeep Pahwa,

R/o C -6/13, Ground Floor,

Vasant Vihar, New Delhi

                                                                                                    .....COMPLAINANT

                                                     VERSUS                                                                                                                          

The Manager

The Oriental Insurance Company Ltd.,

DO-3, 4E/14, Azad Bhawan,

Jhandewalan Extension,

New Delhi – 110 055

                                                                                          …..OPPOSITE PARTY

Ms. Rekha Rani President

Sh. Vikram Kumar Dabas, Member                                                                      Mrs. Manju Bala Sharma, Member

 ORDER                                  Date:   23.04.2018

Sh. Vikram Kumar Dabas

           The complainant had purchased a Mediclaim Happy Family Floater Policy from the OP for an assured sum of Rs. 10,00,000/- .  The policy was valid from 31/07/2014 to 30/07/2015.  The policy was infact a renewal of the old policies without break since 31/07/2002.  On 20/07/2015 the complainant was admitted to Max Health Care Super Speciality Hospital and was discharged on 22/07/2015.  He was allowed cashless treatment.  The expenses on his treatment was to the tune of Rs. 6,17,714/- out of which only a sum of Rs. 3,00,000/- (Rs. Three Lacs) was paid to the complainant and the balance amount of Rs. 3,17,714/- (Three Lacs Seventeen Thousand Seven Hundred Fourteen only) had to be paid by the OP.  The complainant lodged a claim with the OP for the amount spent by him.   The OP however, repudiating the claim citing the exclusion clause 4.1 of the policy terms & conditions.  The complainant had alleged that the OP was guilty of deficiency of service and was liable to pay the full amount of treatment incurred by him.  Hence the complaint.

           The OP has filed a written statement contesting the complaint.  It has denied any deficiency of service on its part and has claimed that the claim lodged by the complainant was rightly repudiated.  The OP however, admitted that it had issued policy of Insurance in favour of complainant as alleged in the complaint.  Para 7 of the written statement (reply on merits) reads as under :       

‘’The contents of this para is denied because as per the terms and conditions of the policy, the disease came under the exclusion clause 4.1 of the policy since the happy family floater policy no. 27220/48/2013/2064  was taken for the first time for the period 2011-2012 after switching over from the individual Mediclaim policy with an increased sum insured of Rs. 10,00,000.00, the disease/treatment remained excluded for the first four years from the inception of the first policy.  And since the happy family floater policy was only in its third year, the treatment did not fall within the terms and conditions and sum insured of this policy.  The policy relevant for the purpose became the individual Mediclaim policy, which was taken four years prior to the policy under which the treatment was taken, that is policy number 272200/48/2011/2269 for the period 31.07.2010 to 30.07.2011 where the sum insured against the name of the complainant was Rs. 3.00 Lacs only, which was paid completely since that was the maximum amount which could be paid for the treatment.  Accordingly, the balance bill of Rs. 3,17,714/- for the treatment had to be paid by the complainant himself.’’  

           The OP has prayed that the complaint be dismissed as it is devoid of any merits.

           The complainant has filed his own affidavit wherein he has reiterated the contents of the complaint filed by him.  OP has also filed an affidavit of evidence and has corroborated the contents of the written statement.

           We have heard arguments advanced at the bar and have perused the record.

           A copy of Happy Family Floater Policy purchased by the complainant has been placed on record.  Clause 4.1 of this policy related to pre-existing health conditions and reads as under :

EXCLUSIONS:  The Company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any Insured Person in connection with or in respect of  :
4.1  Pre-existing health condition or disease or ailment/ injuries: Any ailment / disease / injuries/ health condition which are pre-existing  (treated / untreated, declared / not declared in the proposal from),  in case of any of the insured person of the family, when the cover incepts for the first time, are excluded for such insured person up to 4 years of this policy being in force continuously.

For the purpose of applying this condition, the date of inception of the policy taken from the Company, for each insured person of the family, shall be considered provided the renewals have been continuous and without any break in period.

This exclusion will also apply to any complications arising from pre existing ailments/diseases/ injuries.  Such complications shall be considered as a part of the pre existing health condition or disease.  To illustrate if a person is suffering from hypertension or diabetes or both hypertension and diabetes at the time of taking the policy, then policy shall be subject to following exclusions.

4.3  The expenses on treatment of following ailment/disease/surgeries for the specified period are not payable if contracted and / or manifested during the currency of the policy.

If these diseases are pre-existing at the time of the proposal the exclusion no. 4.1 for pre-existing condition SHALL be applicable in such cases.

 
If the continuity of the renewal is not maintained with the Compnay then subsequent cover SHALL be treated as fresh policy and clauses 4.1, 4.2, 4.3 SHALL apply unless agreed by the Company and suitable endorsement passed on the policy.  Similarly if the sum insured is enhanced subsequent to the inception of the policy, the exclusions 4.1, 4.2 and 4.3 will apply afresh for the enhanced portion of the sum insured for the purpose of this section.

           The OP had repudiated the claim vide letter dated 03/09/2015 which inter alia reads as under :

‘’This is with reference to your legal notice dated 13.08.2015 in the captioned claim.  As per documents submitted by the insured in favour of their claim, the patient was admitted at Max Devki Devi, Delhi from 20/07/2015 to 22/07/2015 & was diagnosed as case of Coronary Artery Disease (CAD), Hypertension, Diabetes, Mellitus Type – II, Dyslipidemia, Hyperuricemia, Depression, Allergic Bronchitis, GERD, Thyroid Disease, LAD & Synergy to prcx. LCx, LVEF-55%.  He underwent CAG (Coronary angiography) which revealed Triple Vessel disease and subsequently PTCA + Stent to mid-distal LAD was done during the hospitalisation period.

The pre auth form showed history of Hypertension for last 25 years & Diabetes Mellitus (recently diagnosed as per discharge card.)  Thus the diagnosed disease (HTN) is pre-existing & HTN &DM (both) are major risk factors of CAD. 

Policy clause 4.1 excludes pre-existing disease for first 4 years of mediclaim policy (enclosed).  We have, therefore, restricted the Sum Insured to policy for the year 2010-2011 (SI 4 years ago) when it was Rs. 3,00,000/- vide policy no. 272200/48/2011/2269 for the period 31/07/2010 to 30/07/2011.

As such, the cashless claim has been settled for Rs. 3,00,000/- out of hospital billed for Rs. 6,17,714/- under file Number 16CB01O1A1469.’’

           We have perused the repudiation letter as also the exclusion clauses in the policy as reproduced above.  Clause 4.3 of the terms and conditions of the policy as reproduced above deals with a case where the sum insured is enhanced subsequent to the inception of the policy and states that the exclusion 4.1, 4.2 & 4.3 will apply afresh for the enhanced portion of the sum insured for the purpose of this section.  In the case of the complainant the policy was allegedly taken in the year 2002.  The sum assured was enhanced from Rs. 3 Lakhs to Rs. 10 Lakhs w.e.f. 31/07/2012.  The exclusion clause provides that in order to get the enhanced sum insured a period of 04 years must have elapsed from the date of enhancement.  Since the sum assured was enhanced on 31/07/2012, the complainant would have been entitled to reimbursement of the enhanced sum insured w.e.f. 31/07/2016 in view of the aforesaid terms of the policy.  Since the complainant was hospitalized from 20/07/2015 to 22/07/2015 and a period of 4 years had not expired clause 4.3 applied in his case.  The complainant was therefore, entitled to the reimbursement of the sum assured as on 31/07/2010 to 30/07/2011.  At the said time the sum insured was Rs. 3 Lakh which has already been paid towards the expenses incurred on his treatment by the complainant. 

We are therefore of the considered opinion that OP was not obliged to the pay the balance sum of Rs. 3,17,714/-(Three Lacs Seventeen Thousand Seven Hundred Fourteen only).It had rightly repudiated the claim of the complainant.We see no merits in this case and the complaint is hereby dismissed.Copy of the order be supplied to the parties as per rules.File be consigned to record room.

Announced on this ______ day of _______ 2018.