Delhi

East Delhi

CC/662/2014

ROHIT - Complainant(s)

Versus

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

24 May 2019

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM (EAST)

GOVT. OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, FIRST FLOOR,

SAINI ENCLAVE, DELHI – 110 092

C.C. NO. 662/14

 

Shri Rohit Ahuja

S/o Late Shri Ram Nath Ahuja

R/o 1/17, Gali No. 4, Main Pandav Road,

Vishwas Nagar, Shahdara, Delhi- 110032     

                                            ….Complainant

Vs.    

1. Oriental Insurance Co. Ltd.

270000- OIC, RO Scope Minar,

1^st Floor, Core I, District Centre,

Laxmi Nagar, Delhi- 110092

 

2. Oriental Insurance Co. Ltd.

Branch Office, Nehru Place,

CBO 17, 57/204 Manjusha Building,

Nehru Place, New Delhi- 110019

 

3. Vipul Medcorp TPA Pvt. Ltd.

515, Udyog Vihar, Phase- V,

Gurgaon- 122016

                                                                                    …Opponent

 

Date of Institution: 23.07.2014

Judgement Reserved on: 24.05.2019

Judgement Passed on: 03.06.2019

 

CORUM:

Sh. Sukhdev Singh (President)

Dr. P.N. Tiwari (Member)

Ms. Harpreet Kaur Charya (Member)

 

Order By: Harpreet Kaur Charya (Member)

 

JUDGEMENT

           Jurisdiction of this Forum has been invoked by Shri Rohit Ahuja, the complainant against, Oriental Insurance Company Ltd., (OP-1) Regional Office, Oriental Insurance Company Ltd. Branch Office Nehru Place Policy issuing office (OP-2) and Vipul Medcorp  TPA Pvt. Ltd., (OP-3).

Facts in brief are that the complainant had purchased Happy Family Floater Policy (Silver Plan) schedule vide policy no. 272102/48/2014/1296 with cover of  Rs. 5,00,000/- for period from 16.08.2013 to 15.08.2014. The complainant was hospitalized from 22.12.2013 to 05.01.2014 in Max Super Specialty Hospital   Patparganj with complaint of pain in abdomen, which was diagnosed as Pancreatitis. On 20.01.2014, a claim of Rs. 5,64,877/-  alongwith original documents was submitted with OP-3 for reimbursement. It has been stated that queries raised by OP-3 were duly replied alongwith certificate of treating doctor of the hospital, but despite that OP failed to settle/ decide the claim of the complainant. Legal Notice dated 24.02.2014 demanding OP to process the claim and release the amount was served, which was duly replied by OP-3, where it was stated that the matter was under examination for further necessary action in the office of AGM, OIC Ltd., Laxmi Nagar Delhi- 110092. The complainant is aggrieved by the failure on the part of OP to take any action on his claim as they have neither released any payment nor repudiated the claim even after a period of 100 days has lapsed.

Hence, the present complaint seeking directions to OP to decide the case and pay Rs. 4,50,000/- spent on hospitalization with interest @18% per annum for the period of delay alongwith cost and compensation.

Policy document has been annexed as Annexure-C1,  claim form as           Annexure-C2, duplicate inpatient bill (Summary), case summary, query details by OP-3 as Annexure-C3, reply dated 26.02.2014 as Annexure-C4, letter by treating doctor as Annexure-C5, Legal notice 24.05.2014 as Annexure-C6, letter by OP-3 dated 02.06.2014, another letter dated 27.03.2014 by OP-3 as Annexure-C8 have been annexed with complaint.

Written Statement was filed on behalf of OP-1 and OP-2 upon the service of summon in the present complaint. They have taken several pleas in their defence such as; the complainant was guilty of suppression of true and correct facts. As per the treatment records/ IPD records the complainant was found to be “Chronic Alcoholic” since 20 years; the present complaint involved complicated question of facts and law which could not be decided in summary proceedings; no deficiency in services could be attributed to OP-1 and OP-2 as the complainant never approached OP-1 and OP-2 at any stage neither at the time of apply for cashless treatment nor any claim was logged with OP-1 or OP-2; the claim was not submitted within 7 days (from date of discharge) as stipulated in the policy terms and conditions; no cause of action had arisen in favour of complainant qua OP-1 and OP-2; territorial jurisdiction was also disputed.

It was submitted that on scrutiny and examination of the treatment record of the complainant, it was found that the complainant was chronic alcoholic, since 20 years the fact which had not been disclosed by the complainant, moreover, the claim was filed on 22.01.2014, whereas the date of discharge was 05.01.2014. Upon receipt of claim documents TPA, duly accredited by IRDA, got the claim investigated through Dr. Ghanendra Singh, who submitted his investigation report upon which OP-3 who were authorized to recommend settlement/ repudiation of the claim on merit, sought clarification alongwith requisite documents. Vide repudiation letter dated 19.09.2014, the claim of the complainant was denied due to Hypertension and Chronic Alcoholism under the exclusion clause no.4.8 of policy terms and conditions. Rest of the contents of the complaint have been denied, with prayer for dismissal of the same with exemplary cost.

OP-1 and OP-2 have annexed policy terms and conditions as                 Annexure OP1&2/A, claim form as Annexure OP1&2/B, reimbursement case investigation sheet as Annexure OP1&2/C, Repudiation letter dated 19.09.2014 as Annexure OP1&2/D.

Rejoinder to the Written Statement filed on behalf of OP-1 and OP-2 was filed by the complainant, where it has been stated that the complainant was not suffering from Hypertension and Chronic Alcoholism as alleged by OP. Rest of the contents of the Written Statement have also been denied and those of the complaint have been reaffirmed.

Evidence by way of affidavit has been filed by both the parties, the complainant has deposed on oath the contents of the complaint and it was stated that during the pendency of the present complaint the repudiation letter dated 19.09.2014 was issued by OP, where the claim was rejected on the grounds that, as per indoor treatment record of the hospital the complainant was a known case of Hypertension and Chronic Alcoholism despite the certificate dated 24.02.2014 by the treating doctor had been given to OP-3. They have further stated that            non-settlement of the claim by OP for sufficiently long period amounted to deficiency in services as well as unfair trade practice. He has relied on the documents annexed with the complaint. 

OP have got examined Shri Jasbir Singh Kalsi, Divisional Manager, Divisional Office-23 as OPW1&2/1, who have also reaffirmed the contents of their Written Statement and have got exhibited copy of policy and terms and conditions (Colly.) as Ex.OP1&2/A; copy of claim form as Ex.OP1&2/B; investigation sheet duly signed by investigator Dr. Ghanendra Singh and Hospital representative as Ex.OP1&2/C. It was submitted that the claim of the complainant was found inadmissible under exclusion clause no. 4.8 of policy terms and conditions, which has been reproduced as under:

“Convalescence, general debility “run down” condition or rest cure, congenital external and internal diseases or defects or anomalies, sterility, any fertility, sub-fertility assisted conception procedure, venereal disease, intentional self-injury/suicide, all Psychiatric And Psychosomatic Disorder and disease/ accident due to and/or use, misuse or abuse of drugs/alcohol or use of intoxicating substances or such abuse or addiction etc”

The said policy terms and conditions had been intimated to the complainant vide letter dated 16.12.2013, copy of repudiation letter has been exhibited as Ex.OP1&2/D.  

In support  of their submissions OP-1 to OP-3 have also got examined       Dr. Pradeep Gupta, Vice- President- Country Head (Claims), M/s Vipul MedCorp Insurance TPA Pvt. Ltd., who has stated that as per indoor patients records of treatment of the complainant, which were duly verified by “Balaji, Medical and Diagnostic Centre” known as Max Super Specialty Hospital, Patpar Ganj, complainant having IP no. 151152 was Diagnosed with “Acute Necrotizing Pancreatitis” and was also a known case of Hypertension and Chronic Alcoholism. He has relied on certified copy of IPD records dated 05.01.2014, 02.01.2014, 26.12.2013 and 25.12.2013 and have got them exhibited as Ex. OP3/A (Colly.) He has also got exhibited the copy of the proposal form and copy of letter dated 27.03.2014 and its reply dated 02.06.2014 as Ex.OP3/B (Colly.).

We have perused the material placed on record and heard the arguments on behalf of the Ld. Counsels for the parties. The issue before us is regarding the           non-settlement of the claim filed with OPs for hospitalization of the complainant for the period from 22.12.2013 to 05.01.2014 for a sum of Rs. 4,50,000/-. The said claim was filed with OP on 20.01.2014 and the same was repudiated vide Repudiation letter dated 19.09.2014 on the grounds that the complainant was known case of Hypertension and Chronic Alcoholism. The said fact has been denied by complainant and in support he has relied upon the letter dated 24.02.2014 issued by the treating doctor, Dr. Ajay Jain.

On the other hand, it has been argued by the Ld. Counsel for OPs that the complainant was a known case of Hypertension and Chronic Alcoholism and in their support they have relied upon Ex.OP3/A (Colly.), which are the daily progress sheets, Department of Critical Care Medicine, Max Balaji Health Care, where on the daily progress sheet dated 25.12.2013, under provisional diagnosis it has been mentioned “K/C/O HTN x 4, Pancreatitis” and on progress sheet dated  02.01.2014 again it is written “H/O Alcohol use x 20 years; ½ to 1 bottle/ per day; last use 10 days back” and the daily progress sheet for 05.01.2014 also bears “K/C/O HTN, Chronic Alcoholism”.

The document relied upon by OP cannot be doubted upon as they are the indoor patient treatment records which cannot be manipulated and tampered (fabricated) with, however, the letter dated 24.02.2014 given by the treating doctor is subsequent to discharge, therefore, it cannot be considered.

Thus, OP has been successful in discharging the onus that there was breach of policy terms and conditions which is further substantiated from the proposal form dated 16.03.2013, which is Ex.OP3/B, where the complainant has answered in “Negative” to the question regarding the “high blood pressure, palpitation, Heart diseases including ischaemic heart diseases, other circulatory disorders including rheumatic fever etc." in personal history. Thus, the complainant had concealed material facts from OP at the time of taking policy.

Therefore, from the above discussion, the present complaint is dismissed being devoid of merits, without order to cost.

Copy of the order be supplied to the parties as per rules.

            File be consigned to Record Room.

 

     

   (DR. P.N. TIWARI)                                                          (HARPREET KAUR CHARYA)

                    Member                                                                           Member    

                                                (SUKHDEV SINGH)

                                                      President