Delhi

East Delhi

CC/384/2015

MR.VIJAY KUMAR - Complainant(s)

Versus

O.I.C - Opp.Party(s)

19 Jan 2018

ORDER

           DISTRICT CONSUMER DISPUTE REDRESSAL FORUM, EAST, Govt of NCT of Delhi

               CONVENIENT SHOPPING CENTRE, 1^st FLOOR, SAINI ENCLAVE, DELHI 110092  

 

                                                                                                   Consumer complaint no.       384/2015

                                                                                                   Date of Institution               27/05/2015

                                                                                                   Order reserved on               19/01/2018        

                                                                                                   Date of Order                       22/01/2018                                                                                     

 

In matter of

Mr Vijay Kumar, adult   

R/o- E-8A/8, Lane  E8,

Block A, Krishna Nagar, Delhi 110051……….……………...…………….Complainant

                             

                                      Vs

 

The Oriental Insurance Co. Ltd.

1/28, Sunlight Insurance Building,

Asaf Ali Road, New Delhi- 110002 …..………………….….…………..Opponent

 

Complainant’s Advocate- Rajesh Kumar Sharma & Pawan Kumar Sharma

Opponent’s Advocate-      Bhupesh Chandna

 

Quorum   Sh Sukhdev  Singh       President

                   Dr P N Tiwari                Member

                   Mrs Harpreet Kaur      Member                                                                                              

 

Order by Dr P N Tiwari  Member  

 

Brief Facts of the case                                                                                                

Complainant, Sh Vijay Kumar, aged 45 years, took Happy Family Floater Policy health cover for himself and his family having three members as Mrs Monika Munish 37 yrs, Mr Harsh Munish, aged 20 yrs and Ms Priyanka, aged 16 yrs (Ex CW1/1A) from Oriental Insurance Co. / OP from 30/08/2012 to 29/08/2013 (Ex CW1/1) vide policy no. 215400/48/2013/3010 for a sum insured to three lacs and Mediclaim policy was renewed regularly up to 30/08/2014 to 29/08/2015 as policy no. 215400/48/2015/2759 (Ex CW1/2 &3) and did not take any claim or had any breakup in policy tenure.  

It was stated that complainant’s wife Smt Monika Munish, insured, was admitted in the Monga Medical Centre, East Delhi on 14/12/2014 (Ex CW1/4 & 4A) with complaints of high fever.

She was treated for one day from 14/12/2014 to 15/12/2015 and was referred to Sir Ganga Ram Hospital at Rajendra Nagar, New Delhi where she remained admitted from 15/12/2014 to 26/12/2014 (Ex CW1/5&5A).

It was stated that all the formalities of claim process was done by the complainant on 02/01/2015, but OP repudiated their claim on 03/03/2015 under exclusion clause 4.1 on the ground that all the diagnosed diseases were pre existing (Ex CW1/6).

Complainant filed this complaint after all his efforts failed to get any relief from OP, so claimed a sum of Rs 2,19,897/-with 24% interest and compensation of Rs 2 lacs for harassment with   litigation charges Rs 25,000/-.  

 

After receiving notices, OP submitted written statement denying all allegations of deficiency of OP. It was submitted that claim was rightly rejected under exclusion clause 4.1 of policy terms and conditions. It was also submitted that the claim was in third year policy and the diagnosed diseases as T2DM, Ulcerative Colitis, Hypothyroidism, Ventra Hernia, Morbid Obesity, Sepsis and Hypo-vitaminosis D as per the discharge summary of Sir Ganga Ram Hospital.

OP stated that the claimed ailments were falling under the exclusion clause 4.1 ie pre existing, (Ex OPW1/1) as their terms and conditions of the said mediclaim policy.  Hence, prayed for the dismissal of this complaint as there was no deficiency in their services.

 

Complainant had filed his rejoinder to the written statement and denied the replies submitted by OP. He also submitted his evidences on affidavit and affirmed on oath himself that all the facts and evidences were true and correct and nothing had been submitted wrongly or hidden.

OP submitted their evidences on affidavit through Mr Subhash Chandra, Deputy Manager working with OP and affirmed on oath that the present claim was lodged in 3^rd years policy and as per their terms and conditions, the diagnosed ailments were pre existing. It was also submitted that the complainant had committed fraud under exclusion clause 5.9 by concealing the material facts about the diagnosed ailments in her policy proposal form (Ex OPW1/1).

It was admitted that the OP had not taken any medical examination of the insured as their age was less than 45 years at the time of taking mediclaim policy in 2012.

 

OP also submitted two citations in support of their repudiation justified as- NIAC vs Rekha Malhotra & others in RP 1009/2015, 2016 STPL 15645 NC decides on 26/10/2016 and  LIC of India vs  Ramphal in RP 1479/2016, 2017 STPL 729 NC decided on 04/10/2016.     

 

Arguments were heard from both the parties and order was reserved.

Before coming to the conclusion of this case, I have framed some clarifications / explanations as under –

1. Whether all diagnosed diseases fall under exclusion clauses 4.1 of terms and conditions of the policy?
2. Whether repudiation of claim was justified by OP in reference to 4.1 in reference to two citations by OP? 

1- Whether all diagnosed diseases fall under exclusion clauses 4.1 under terms and conditions of the policy?

By taking the reference of terms and condition under Exclusion clause 4.1 specifically in Ex. OPW1/1, it clearly mentioned that Diabetes and its complications are not covered up to the limitation of two years under sub clause xviii. Here in this case, complainant has not taken any claim for Diabetes under indoor care and his policy is continue. Hence, all the treatment pertaining to the Diabetes is payable under this 3^rd year policy cover. 

AS FAR AS OTHER DIAGNOSIS ARE CONCERENED AS ULCERATIVE COLITIS, HYPOTHYROIDISM, VENTRAL HERNIA, MORBID OBESITY, SEPSIS AND HYPOVITAMINOSIS D, EXCEPT SEPSIS IS A ACUTE MENISFESTATION OF ANY INFECTION IN THE BODY AND WHERE A PATIENT/CLAIMANT IS SUFFEREING FROM DM, IT IS A VERY COMMON KNOWN COMPLICATION; THOUGH ALL OTHER DIAGNOSIS ARE CHRONIC IN NATURE AND MAY PRESENT IN ‘ACUTE’ FORM.

This fact is based on the medical knowledge and qualification as all these diagnosed diseases are chronic in nature and came to the knowledge of opponent at the time of scrutinizing claim documents.  

By seeing terms and conditions under 4.1 and 4.3 in exhibit (OPW1/1), all other ailments written in the discharge summary were not present in the terms and conditions pertaining to exclusion though no treatment was taken by the insured/wife of the complainant as indoor case for listed diagnosis except Diabetes and Sepsis in the discharge summary of treating hospital (Sir Ganga Ram Hospital).  

2-Whether repudiation of claim was justified by OP in reference to 4.1 in reference to two citations by OP? 

After scrutinizing in detail for terms and conditions of the said policy, repudiation was done by OP merely on the basis of noting in the discharge summary and OP failed to submit any concrete evidence on record to prove their repudiation on the terms of 4.1/Pre existing diseases without following set guidelines for the repudiation as justified issued by the Hon. Supreme Court in many such cases.  

We have also gone through two citations submitted by OP as -1- NIAC vs Rekha Malhotra & others (supra), claim repudiation was justified under 4.1 exclusion clause as policy was in first year and claim was filed within two months. But here, policy is in 3^rd year and claim procedures have not been followed properly by OP and complainant; hence this citation was not applicable.

As far as second citation is concerned as- LIC vs Ramphal (supra), claim was repudiated on the ground that OPD treatment was not payable, so repudiation was justified, but here facts are different as OP has not proved 4.1 by any evidence. So, this citation was  also not applicable.  

More so, here OP had repudiated the claim at the outright under the mandatory condition 2.3 as first hospitalization (Ex CW1/1) was less than 24 hours, also complainant has not submitted complete and proper treatment documents to see whether the claimant/wife of the complainant was ‘Referred or Shifted’ to other hospital (Ex CW1/2), but OP’s rejection letter (Ex CW1/6) showed a continuous admission and discharge from second treating hospital/Sir Ganga Ram Hospital.  

 

 

After going through entire facts and evidences on record, we came to the conclusion that the present complaint is devoid of any merit and deserves to be dismissed without any direction.

Copy of this order be sent to the parties as per section 18 of the Consumer Protection Regulation 2005 (in short CPR) and file be consigned to Record Room under section 20(1) of the CPR.  

 

(Dr) P N Tiwari,  Member                                                                       Mrs  Harpreet Kaur,  Member                                                                                                                         

                                      

                                                     Sukhdev Singh  President